"Nursing Physicians and Clinicians"

[Boatswain2PA]

I think we all felt that way on july 1. I jokingly tell the interns, you're basically a MS5 except the coat is longer and the safety net just got a lot smaller
with this new program that's at least 1 mo of supervision. a brand new PA/NP starts with none.

Untrue statement. PA's are supervised by physicians. It is up to the physician and physician assistant to determine what the appropriate level of supervision is.

Nurse Practitioners are pushing for total independence, and they have legislatively attained that goal in many states.

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[Birdstrike]

This is the pivotal point of this whole thread. Physicians need to be owners not employees. If you are an owner instead of an employee, then you can hire/fire as seen fit and you profit off of employing midlevels. That's the only way it makes sense for a physician. I know I sound the SDG trumpet frequently on here, but it's because it's the only model that adequately protects the interests of the EM physician. If you told me SDGs were no longer an option and presented me instead with some of the terrible work environments described on here, I can honestly say I would walk. I would sooner open my own FSED or open up more urgent cares than work in a toxic unstable environment.

Considering the overall trend is for physicians in all specialties to choose employment or to be swallowed up as employees, and the overall trend is for SDGs to fall to CMGs, isn't it going to take a hell of a fight for physicians in all specialties (not just Emergnmcy Medicine) to remain indepenent?

In some specialties, you have Medicare paying 500-600% greater (no that's not a misprint) for the same services done in a hospital, by hospital employed doctors, compared to physicians in private practice. I couldn't think of a better concerted effort to kill off independent physician private practice if I designed it myself. There's some very, very powerful people that want to make private physician practice impossible and have doctors under their full control.

 

[MSmentor018]

Untrue statement. PA's are supervised by physicians. It is up to the physician and physician assistant to determine what the appropriate level of supervision is.

Nurse Practitioners are pushing for total independence, and they have legislatively attained that goal in many states.

boats when you started did you get a tightly mandated supervisory day/week/month? considering the liability in this MO program that's what it sounds like. almost like another med student rotation. in the academic shop I am at, the PA/NP are supervised just like residents, meaning each pt is presented to an attending. I try to see them if I get a chance mostly just to eyeball and press ganey. in the community center the PA don't present and I see the charts throughout the shift or home but I never see the pt. sure, they can come ask us for advice but they haven't yet.....some are new grads.

I know there's a fellowship (we have it here) but i've only had 1 PA do it in 5 yrs of being here. is it worth doing for PA's? not popular? do you feel more comfortable afterwards?

the whole NP indep thing is a little hokey. tell me if this is true....after dissecting the education requirements, knocking off theories of nursing and other philosophical niches of nursing, NP school has less core medical classes (credits) than PA's. I was chatting with anesthesia (OR cases only), FP, EM at lunch the other day and they seem to notice a difference. just wanted your opinion.

 

[Boatswain2PA]

boats when you started did you get a tightly mandated supervisory day/week/month? considering the liability in this MO program that's what it sounds like. almost like another med student rotation. in the academic shop I am at, the PA/NP are supervised just like residents, meaning each pt is presented to an attending. I try to see them if I get a chance mostly just to eyeball and press ganey. in the community center the PA don't present and I see the charts throughout the shift or home but I never see the pt. sure, they can come ask us for advice but they haven't yet.....some are new grads.

I know there's a fellowship (we have it here) but i've only had 1 PA do it in 5 yrs of being here. is it worth doing for PA's? not popular? do you feel more comfortable afterwards?

the whole NP thing is a little hokey. tell me if this is true....after dissecting the education requirements, knocking off theories of nursing and other philosophical niches of nursing, NP school has less core medical classes (credits) than PA's. I was chatting with anesthesia (OR cases only), FP, EM at lunch the other day and they seem to notice a difference. just wanted your opinion.

I did not, but most of my classmates did/do (get a tightly supervised job right out of school). However I came from a strong emergency management/medical background and I have decades more experience than most of my classmates.

PA residencies/fellowships are growing. With the change of demographics of PA students (With 20 years of military and SAR experience I was a throwback, most of my classmates were 23 year old mensa types) very few new PA grads have much in the way of medical (or life) experience, so residencies/fellowships will soon be the norm. This goes hand-in-hand with the creation of the Certificate of Additional Qualification (CAQ) for PA specialties. The Society of Emergency Medicine Physician Assistants (SEMPA) worked hand-in-hand with ACEP when creating the requirements for the EM CAQ, including (I believe) writing the examination. I think ACEP and SEMPA are paving the way for how physician/physician assistant specialty organizations should work together.

But none of this changes the fact that PAs are supervised by you guys...the "real" docs. Whether I present every patient to you like a resident, or you sign off on my charts at oh-dark-thirty, you're still supervising me. Birdstrike brings up some incredibly important points, but they seem to be based more on how administration has neutered your ability to supervise/manage your department and your mid-levels. If you are working in a community center supervising PAs, then I suggest you take some time to get to know that PA and their knowledge/abilities. I always appreciated it when my attending swung by the ED after clinic to say hi, ask how it was going, and see if I needed any help. Gave me a chance to get feedback from him, which helped me run the ED the way he wanted me to.

Yes, to be politically incorrect (I do that a lot)....much of NP education is a joke. There are some great NPs out there, but they were either the very experienced nurses before going NP, or they received very good OJT training after their program. PA education >>>>>>>>> NP education. However that doesn't mean every PA > every NP.

 

[MSmentor018]

I did not, but most of my classmates did/do (get a tightly supervised job right out of school). However I came from a strong emergency management/medical background and I have decades more experience than most of my classmates.

PA residencies/fellowships are growing. With the change of demographics of PA students (With 20 years of military and SAR experience I was a throwback, most of my classmates were 23 year old mensa types) very few new PA grads have much in the way of medical (or life) experience, so residencies/fellowships will soon be the norm. This goes hand-in-hand with the creation of the Certificate of Additional Qualification (CAQ) for PA specialties. The Society of Emergency Medicine Physician Assistants (SEMPA) worked hand-in-hand with ACEP when creating the requirements for the EM CAQ, including (I believe) writing the examination. I think ACEP and SEMPA are paving the way for how physician/physician assistant specialty organizations should work together.

But none of this changes the fact that PAs are supervised by you guys...the "real" docs. Whether I present every patient to you like a resident, or you sign off on my charts at oh-dark-thirty, you're still supervising me. Birdstrike brings up some incredibly important points, but they seem to be based more on how administration has neutered your ability to supervise/manage your department and your mid-levels. If you are working in a community center supervising PAs, then I suggest you take some time to get to know that PA and their knowledge/abilities. I always appreciated it when my attending swung by the ED after clinic to say hi, ask how it was going, and see if I needed any help. Gave me a chance to get feedback from him, which helped me run the ED the way he wanted me to.

Yes, to be politically incorrect (I do that a lot)....much of NP education is a joke. There are some great NPs out there, but they were either the very experienced nurses before going NP, or they received very good OJT training after their program. PA education >>>>>>>>> NP education. However that doesn't mean every PA > every NP.

thanks for the feedback, like you I came from a military background. I was #4 oldest in my med school class, oldest in my residency, and #5 oldest in my group. so my thoughts are definitely skewed compared to the 27 yr old new attending graduate.

I know most of the PA's very well and they like me, that's worth it's weight in gold. every now and then a chart comes up and I get a run of PVC's. I actually call and check up on the pt. only had to call back 2 to the ER in the last year. but birdstrike is right, with the way admin wants to run us, it's hard for us to supervise and run an effective ED. problem is too many cooks and they've never been in a kitchen

so the NP program has the least education and asking for the most independence. is there something wrong about this picture?

 

[Makati2008]

I did not, but most of my classmates did/do (get a tightly supervised job right out of school). However I came from a strong emergency management/medical background and I have decades more experience than most of my classmates.

PA residencies/fellowships are growing. With the change of demographics of PA students (With 20 years of military and SAR experience I was a throwback, most of my classmates were 23 year old mensa types) very few new PA grads have much in the way of medical (or life) experience, so residencies/fellowships will soon be the norm. This goes hand-in-hand with the creation of the Certificate of Additional Qualification (CAQ) for PA specialties. The Society of Emergency Medicine Physician Assistants (SEMPA) worked hand-in-hand with ACEP when creating the requirements for the EM CAQ, including (I believe) writing the examination. I think ACEP and SEMPA are paving the way for how physician/physician assistant specialty organizations should work together.

But none of this changes the fact that PAs are supervised by you guys...the "real" docs. Whether I present every patient to you like a resident, or you sign off on my charts at oh-dark-thirty, you're still supervising me. Birdstrike brings up some incredibly important points, but they seem to be based more on how administration has neutered your ability to supervise/manage your department and your mid-levels. If you are working in a community center supervising PAs, then I suggest you take some time to get to know that PA and their knowledge/abilities. I always appreciated it when my attending swung by the ED after clinic to say hi, ask how it was going, and see if I needed any help. Gave me a chance to get feedback from him, which helped me run the ED the way he wanted me to.

Yes, to be politically incorrect (I do that a lot)....much of NP education is a joke. There are some great NPs out there, but they were either the very experienced nurses before going NP, or they received very good OJT training after their program. PA education >>>>>>>>> NP education. However that doesn't mean every PA > every NP.

I agree with you on everything. I just wish the CAQ requirements had to be signed off by an EP. I have seen some FPs sign off on the requirements when they struggle with some of the procedures on the list

 

[Birdstrike]

thanks for the feedback, like you I came from a military background. I was #4 oldest in my med school class, oldest in my residency, and #5 oldest in my group. so my thoughts are definitely skewed compared to the 27 yr old new attending graduate.

I know most of the PA's very well and they like me, that's worth it's weight in gold. every now and then a chart comes up and I get a run of PVC's. I actually call and check up on the pt. only had to call back 2 to the ER in the last year. but birdstrike is right, with the way admin wants to run us, it's hard for us to supervise and run an effective ED. problem is too many cooks and they've never been in a kitchen

so the NP program has the least education and asking for the most independence. is there something wrong about this picture?

Nobody wants to answer this question, so I'll ask it again, rephrased:

Wouldn't you rather work in a department where the midlevels (PA or NP) see their own patients, are independent, perhaps even work in a separate low acuity pod, and are employed by the hospital (not you or your group), are covered by their own medmal policy without your name on it, and without any need for a "supervising doctor" to hang their hat on medico-legally?

In that scenario you wouldn't be liable, you wouldn't have to slow down to staff patients with them, you wouldn't have to co-sign any charts, hire them/fire them or have to worry about your group affording their salary/benefits/production, etc. They'd be their own little birdie, wings a flapin' on their own. How would that be worse for you? To me, the whole extender scenario collapses under it's own weight when all of a sudden the physician is 100% responsible, yet has little if any control, and little to gain from the partnership. To those that think their group is taking in big bucks on midlevels, skimming off their production, have you looked at the numbers? Are you so sure, that after salary, med mal, benefits, funding accounts receivables and all the other expenses that you're even breaking even, once balancing out the high vs. low producers and the drag on your production to supervise?

Greg Henry wrote somewhere (I think, correct me if wrong) that there may be a day where departments are comprised of ratios of one EP to 6-8 midlevels, with huge supervision burdens to meet the needs of the system (I'll look for reference later).

That's where some very smart people think things are going, and if they get their way, do you want to be legally responsible for 6-8 midlevels and hundreds of patients per shift, or cut the cord and let them fly solo?

 

[Boatswain2PA]

Bird - I see your point. You seem to be an isolationist who wants to "just" practice medicine, and not be involved with any of the "management stuff" or responsibilities of anything except your patients. However this is the kind of attitude that is allowing NPs to continue to push for independent practice. Worse yet, it is attitudes like this, on top of the NPs successful pushes, that now has some PAs arguing for greater independence.

But again, your proposal sounds great....until it is your 18 year old granddaughter (yes, you'll eventually have one) who lives 3 states away from you who presents to the ED with severe abdominal pain and gets stuck with that new grad NP flying without any kind of supervision.

I thought our first duty was to our patients?!?

 

[Boatswain2PA]

I agree with you on everything. I just wish the CAQ requirements had to be signed off by an EP. I have seen some FPs sign off on the requirements when they struggle with some of the procedures on the list

In a perfect world you would be right, and it will probably come to fruition in a couple of decades when a requirement to take the EM CAQ includes graduation from a residency. However, if implemented today, that would completely preclude me from attaining the CAQ as I haven't worked with an EP since school.

 

[RustedFox]

Nobody wants to answer this question, so I'll ask it again, rephrased:

Wouldn't you rather work in a department where the midlevels (PA or NP) see their own patients, are independent, perhaps even work in a separate low acuity pod, and are employed by the hospital (not you or your group), are covered by their own medmal policy without your name on it, and without any need for a "supervising doctor" to hang their hat on medico-legally?

In that scenario you wouldn't be liable, you wouldn't have to slow down to staff patients with them, you wouldn't have to co-sign any charts, hire them/fire them or have to worry about your group affording their salary/benefits/production, etc. They'd be their own little birdie, wings a flapin' on their own. How would that be worse for you? To me, the whole extender scenario collapses under it's own weight when all of a sudden the physician is 100% responsible, yet has little if any control, and little to gain from the partnership. To those that think their group is taking in big bucks on midlevels, skimming off their production, have you looked at the numbers? Are you so sure, that after salary, med mal, benefits, funding accounts receivables and all the other expenses that you're even breaking even, once balancing out the high vs. low producers and the drag on your production to supervise?

Greg Henry wrote somewhere (I think, correct me if wrong) that there may be a day where departments are comprised of ratios of one EP to 6-8 midlevels, with huge supervision burdens to meet the needs of the system (I'll look for reference later).

That's where some very smart people think things are going, and if they get their way, do you want to be legally responsible for 6-8 midlevels and hundreds of patients per shift, or cut the cord and let them fly solo?

This.

 

[GeneralVeers]

The reality is that the system(s) are broken. Medicare is broke. Medicaid is broke. The VA is broke, and private insurance is unsustainable in an ACA world. Costs will have to be cut. Hospitals are run by beancounters, and if they think they can save 50% by replacing physicians with midlevels they will do it. There is little choice we have in this matter, as all the big decisions are being made at levels way above us. I agree that the future model will be the hospital employed EP supervising several midelevels at any one time.

 

[@JackShephard]

The reality is that the system(s) are broken. Medicare is broke. Medicaid is broke. The VA is broke, and private insurance is unsustainable in an ACA world. Costs will have to be cut. Hospitals are run by beancounters, and if they think they can save 50% by replacing physicians with midlevels they will do it. There is little choice we have in this matter, as all the big decisions are being made at levels way above us. I agree that the future model will be the hospital employed EP supervising several midelevels at any one time.

A perfect summary of the current state of healthcare.

 

[@JackShephard]

Nobody wants to answer this question, so I'll ask it again, rephrased:

Wouldn't you rather work in a department where the midlevels (PA or NP) see their own patients, are independent, perhaps even work in a separate low acuity pod, and are employed by the hospital (not you or your group), are covered by their own medmal policy without your name on it, and without any need for a "supervising doctor" to hang their hat on medico-legally?

In that scenario you wouldn't be liable, you wouldn't have to slow down to staff patients with them, you wouldn't have to co-sign any charts, hire them/fire them or have to worry about your group affording their salary/benefits/production, etc. They'd be their own little birdie, wings a flapin' on their own. How would that be worse for you? To me, the whole extender scenario collapses under it's own weight when all of a sudden the physician is 100% responsible, yet has little if any control, and little to gain from the partnership. To those that think their group is taking in big bucks on midlevels, skimming off their production, have you looked at the numbers? Are you so sure, that after salary, med mal, benefits, funding accounts receivables and all the other expenses that you're even breaking even, once balancing out the high vs. low producers and the drag on your production to supervise?

Greg Henry wrote somewhere (I think, correct me if wrong) that there may be a day where departments are comprised of ratios of one EP to 6-8 midlevels, with huge supervision burdens to meet the needs of the system (I'll look for reference later).

That's where some very smart people think things are going, and if they get their way, do you want to be legally responsible for 6-8 midlevels and hundreds of patients per shift, or cut the cord and let them fly solo?

Great post.

Why I agree with Bird? The end game is dismal. I couldn't imagine seeing patients and supervising 4-7 other midlevels entire patient loads. That's our end game.

If hospitals want to use tons of midlevels, fine. Let's make it a competition. It's essentially our advanced training and thinking vs theirs.

Everyone talks about how there are some dumb doctors out there or occasional bad eggs. Can you imagine how many terrible midlevels that would be exposed if they had to practice independently? They will make some terrible mistakes. Sure, I want to protect our patients - but the midlevels have a huge variance in quality (some great, some AWFUL). So if you give me the choice between managing 5 midlevels of questionable quality to earn about the same pay as I would just doing my own job... well, let them do their thing. Let America and everyone else realize why the hell we all went to med school. There's a difference, but the difference is hidden behind supervision.

The hospital administrators end game is to have us all doing 5 times the work for the same salary. Don't let them turn us into managers.

 

[@JackShephard]

Bird - I see your point. You seem to be an isolationist who wants to "just" practice medicine, and not be involved with any of the "management stuff" or responsibilities of anything except your patients. However this is the kind of attitude that is allowing NPs to continue to push for independent practice. Worse yet, it is attitudes like this, on top of the NPs successful pushes, that now has some PAs arguing for greater independence.

But again, your proposal sounds great....until it is your 18 year old granddaughter (yes, you'll eventually have one) who lives 3 states away from you who presents to the ED with severe abdominal pain and gets stuck with that new grad NP flying without any kind of supervision.

I thought our first duty was to our patients?!?

It's not in our patient's best interest to have us overseeing 5 times as many patients. How does that work? Eventually you aren't taking the histories, doing the physical exams and your basically leaning on someone else's clinical judgement and intuition.

An example: I can't find the article, but I read that one Family Medicine practice hired a psychiatrist to oversee thousands of patients per month. They basically reviewed a chart and made medication changes based on that. No seeing the patients, practicing their craft, etc. Just read the chart and agree or disagree with the medication change.

I'd rather see all the patients I treat!

 

[deleted6669]

I agree with you on everything. I just wish the CAQ requirements had to be signed off by an EP. I have seen some FPs sign off on the requirements when they struggle with some of the procedures on the list

For the em caq at least you do need a procedural sign off from an emergency physician. I was in the first cohort to take and pass this test.

 

[Makati2008]

For the em caq at least you do need a procedural sign off from an emergency physician. I was in the first cohort to take and pass this test.

That's a good compromise. What procedures do you have to do?

 

[Birdstrike]

Bird - I see your point. You seem to be an isolationist who wants to "just" practice medicine, and not be involved with any of the "management stuff" or responsibilities of anything except your patients. However this is the kind of attitude that is allowing NPs to continue to push for independent practice. Worse yet, it is attitudes like this, on top of the NPs successful pushes, that now has some PAs arguing for greater independence.

But again, your proposal sounds great....until it is your 18 year old granddaughter (yes, you'll eventually have one) who lives 3 states away from you who presents to the ED with severe abdominal pain and gets stuck with that new grad NP flying without any kind of supervision.

I thought our first duty was to our patients?!?

There's a lot of ad hominem in this, "you're this...you're that." It attacks the person not the argument.

Yes my first duty is to my patients. MY patients, and I want full control of the cases. I'm that much of a doctor. I want to delegate nothing, so they get the best, as I see it.

Your example of "my grand daughter" (when I have one) is no different than arguing that if one case of a child with meningitis (my child) is missed by a general ER doc then all children MUST be seen by a Peds fellowship trained EP.

 

[Boatswain2PA]

No attacks here Bird. I have a great deal of respect for you for both being an EP and for your various writings.

If a physician wants to delegate nothing, then I think they should be able to practice in that setting. However many physicians see the benefit of properly-trained mid-levels helping share the load.

I wasn't trying to use a "your grand daughter" case as an example of a provider missing a diagnosis, we will all do that and nothing can change that. I was inserting that case into the system that you propose that would allow a new NP to see ED patients without any sort of supervision.

 

[Boatswain2PA]

For the em caq at least you do need a procedural sign off from an emergency physician. I was in the first cohort to take and pass this test.

Where does it say that? The NCCPA EM CAQ site just says "supervising physician" who "works in the field". There are many areas of the country where there ARE no EPs.

 

[deleted6669]

That's a good compromise. What procedures do you have to do?

Airway Adjuncts: Invasive Airway Management
• Intubation
• Mechanical ventilation
• Capnometry
• Non-invasive ventilatory management
Anesthesia
• Local, digital
• Procedural anesthesia, conscious sedation
Advanced Wound Management
• Incision & drainage, wound debridement
• Superficial/deep wound closure
Diagnostic/Therapeutic Procedures
• Soft tissue and joint aspiration
• Lumbar puncture
• Slit lamp examination
• Thoracentesis, thoracostomy
• Tonometry
• Control of epistaxis
• Electrocardiographic interpretation
• Cardiac pacing
• Defibrillation/cardioversion
• Clearing a cervical spine
• Fracture/dislocation management
Hemodynamic Techniques
• Peripheral venous access
• Arterial access for diagnostics and placement of arterial lines
• Central venous access
• Intraosseous infusion
Resuscitation
• Cardiopulmonary
• Fluid

 

[deleted6669]

Where does it say that? The NCCPA EM CAQ site just says "supervising physician" who "works in the field". There are many areas of the country where there ARE no EPs.

An FP doc working full time in em also qualifies.

 

[exsanguination]

Geez, after reading this thread and the one about JDs saying how its so easy to win a suit when a doc "neglects" to order a test that would have "sealed the diagnosis" you'd think that EM as a specialty is useless in the new age of medicine.

Shotgun all the tests (hospital makes money), insert them into some DDx algorithm (cheaper than an MD), have a consultant see and admit them (business for consultant), and patient is happy because "something" was done.

I just hope I can get 10-15 years of practice time in before I'm sued or replaced FULLY by an NP. It'll happen too because he LAST PERSON anybody cares about in the hospital is the EP.

 

[@JackShephard]

Geez, after reading this thread and the one about JDs saying how its so easy to win a suit when a doc "neglects" to order a test that would have "sealed the diagnosis" you'd think that EM as a specialty is useless in the new age of medicine.

Shotgun all the tests (hospital makes money), insert them into some DDx algorithm (cheaper than an MD), have a consultant see and admit them (business for consultant), and patient is happy because "something" was done.

I just hope I can get 10-15 years of practice time in before I'm sued or replaced FULLY by an NP. It'll happen too because he LAST PERSON anybody cares about in the hospital is the EP.

Just wait for one person to die from "computer error".

"Watson told me to do it!"

That will go over well. American's can't even give up suing their physicians, I can't imagine how they would react to trying to sue Watson as their only recourse.

 

[Hercules]

Considering the overall trend is for physicians in all specialties to choose employment or to be swallowed up as employees, and the overall trend is for SDGs to fall to CMGs, isn't it going to take a hell of a fight for physicians in all specialties (not just Emergnmcy Medicine) to remain indepenent?

In some specialties, you have Medicare paying 500-600% greater (no that's not a misprint) for the same services done in a hospital, by hospital employed doctors, compared to physicians in private practice. I couldn't think of a better concerted effort to kill off independent physician private practice if I designed it myself. There's some very, very powerful people that want to make private physician practice impossible and have doctors under their full control.

You guys post too fast for me to keep up. Yes, I do believe it will take a fight for physicians to control their own destiny and remain independent but I don't think it's hopeless. I agree with you that at present there are some powerful forces pushing for a single payer system that uses doctors as employees. I also know that from time to time crystal balls have been cloudy and climates change unexpectedly, so I tend to base my business decisions largely on the landscape as it exists tempered somewhat by predictions of what it may become. Presently, there are options and opportunities that let you hedge your bets as an Emergency Physician. FSEDs and UCs are a great opportunity for independence that are worth taking advantage of for those willing to take on the risk.

 

[Arcan57]

Owning a FSED or an UC is a fine way to make money (in the right environment), but they don't have anything to do with practicing emergency medicine. Also, being the employee for someone else's FSED or UC isn't exactly a path to riches.

 

[MSmentor018]

I don't know of a single PA with a PhD who introduces him/herself as "doctor" in a clinical setting. Academic settings are, of course, different, but we know better than to do that in the clinical settings. Furthermore, the first Pharm/PT/Audiologist/NP/Plumber with a PhD in Music who introduces themselves to my patient as a "Doctor" will be quickly corrected.

I just did.... went to an ent, got totally fooled when she said she was dr x. did an H&P but the exam was a little off so I started asking questions. later she said "oh i am not a doctor, iam a audiologist but have a phd". I gently reminded her a doctorate makes her a doctor not.

 

[ketosisevangelist]

A nurse with a Ph.D is a Doctor.

 

[RustedFox]

A nurse with a Ph.D is a Doctor.

Not a physician, no.

In the medical setting, a distinction needs to be made - otherwise, its fraudulent.

 

[HooliganSnail]

In med school I worked with an NP on my surgical rotation who just got her DNP and went around insisting that everyone refer to her as "Dr. soandso." I remember thinking that that was a great way to confused the **** out of the patients.

When I was a med student I had a several instances where a mid-level told me something I thought was wrong, but I went along with it because I was just a inexperienced med student. Every time I ended up looking like a complete idiot in front of my attending. Moral of the story. If a mid-level ever disagrees with you about something that you are even minutely sure about, they are wrong and you are right.

 

[HooliganSnail]

And THIS!!!!!!!!!!!!!!!!

It is idiotic to think otherwise! Anesthesia thought they were safe too! We need to take a collective stand! PAs for most part recognize their role...But NPs!?!?!?!?

IMHO, this is a huge elephant in the room and simply saying "we have more experience, training, intelligence, ________ (whatever) and we're irreplaceable" is absurd, yet I hear it all the time from many of my faculty.

(another anecdote which occurred on shift yesterday: adolescent male comes in with SEVERELY altered mental status (didn't know where he was, non-sensical fragmented speech, GCS well below 15), bilateral battles signs, ecchymosis all over face, neck pain, etc after pretty bad bicycle accident....From the doorway (Re: less than 3 seconds of seeing patient) I whisper to staff that patient needs head CT and cervical CT (at minimum). But this is an NPs patient......NP is in room for about 20ish minutes and comes out and says "patient looks pretty stable, probably just needs a neck x-ray." Well, kid had a large open, depressed skull fracture amongst many other findings....so after he was admitted to Neurosurgery and booked for urgent OR case by the attending physician the NP says to one of the nurses that "I feel like I can handle most any trauma patients."

Sure, this is N=1. But there is a HUGE difference between a residency trained MD/DO and an NP...Especially as things start to "get real."

I hear stories like this all the time. I even have a few of my own.

Have you ever heard of Dunning-Kruger effect. It is my favorite bias. It has two parts.

1. A novice has a tendency to overestimate their skills, theoretically because they are not experienced enough to realize what they do not know. (NPs)

2. An expert has a tendency to underestimate their skill level, presumably because they assume that what is easy for them is easy for everyone else. (MD/DO)

I agree with you that it is important not to just state that we are better trained, and yada yada yada, but to illustrate all the ways that our training makes us superior. In a lot of ways, that simply means communicating better with our patients and our staff. Explaining why we think what we do, why we are ordering (or not ordering) certain tests, and explaining to patients and families why we are (or are not) concerned about their symptoms.

 

[HooliganSnail]

99.5% of time I agree with Birdstrike. Not this time. This is the typical "Bravado" response.

I'm EXTREMELY pro-physician and pro-EM physician because like most on this board, I have paid the cost to be the boss. The extremely competitive pre-medical world, competing against a lot of the best and brightest just for a chance to get in. The extremely rigorous 4 years of medical school. The non-stop intensity of residency training. I see how hard my fellow medical students, residents and attendings have worked to get to where they're at. And I respect the hell out of them for it. I respect what they've done and who they've become. I understand and appreciate how far they've come in their knowledge and skills.

So yes, I have a problem that a large cohort of people think they can be an RN, take some online courses on health law, policy and leadership, put in a few hundred light hours of patient contact and call themselves my equal. Doesn't matter that they obviously aren't. Why go to medical school? Why do residency? If all you need to do in order to independently practice medicine is to get your DNP. What of this specialty that I've grown to love? What do I tell medical students who seem equally excited about pursing EM? What about the scores of future EM physicians with 300K+ debt? Be a fully independent and EQUAL Nursing Physican (and, yes, I've gotten word that our own university NP program is now marketing themselves as Nursing Physicans) for ONE TENTH (at best) the time/skill and cost investment?

We are completely minimizing ourselves!

Again, we are hurting future EM physicians! Are Academic faculty going to care? No, they think (Re: Think) they're safe and protected in their ivory towers. They're sold a false bill of goods by administration that they're somehow helping the greater public at large by churning out more and more mid-level providers.

To think otherwise is extremely arrogant.

This isn't a question of being insecure, that's ridiculous. This is a question of an extremely cheap alternative that is pseudo-equivalent enough for MOST things in the eyes of administrators (Re: Better bottom line).

What are administrators really concerned with? Clinical outcomes.....or....The financial bottom line?

Sure, call it whatever you want. Just SAVE THIS POST. Because it is coming unless we protect ourselves. Like Anesthesia, we are minimizing ourselves. At least I'll be able to say I told you so. Though I dread the day.

I sincerely hope that I am wrong, but I fear that ultimately I won't be.

I have to agree with this post. I fear that a fight is coming/ is already here. I definitely don't want to end up like anesthesia.

I think they only thing that will keep them at bay is that the average American does not want to see the NP, they want to see the doctor.

 

[LiamNeesons]

I think they only thing that will keep them at bay is that the average American does not want to see the NP, they want to see the doctor.

However, in an emergency, you see whoever is employed.

 

[Boatswain2PA]

I just did.... went to an ent, got totally fooled when she said she was dr x. did an H&P but the exam was a little off so I started asking questions. later she said "oh i am not a doctor, iam a audiologist but have a phd". I gently reminded her a doctorate makes her a doctor not.

Good for you. I'm a little bit more blunt. "So....you're like a Doctor Pepper kind of Doctor, not a real doctor!?!"

 

[Boatswain2PA]

A nurse with a Ph.D is a Doctor.

That nurse has earned a doctorate, so in an academic setting has (kind of) earned the title doctor. So has the janitor who has a PhD in violin. But he shouldn't walk into a patient room and introduce himself to the patient as "Doctor".

 

[MSmentor018]

Good for you. I'm a little bit more blunt. "So....you're like a Doctor Pepper kind of Doctor, not a real doctor!?!"

yeah i am usually an dingus <---this isn't the word I wrote! about those kind of introductions for example: when pt's family at the bedside wears a lab coat (they're not on duty or a physician), does the name dropping thing before the exam starts, or my favorite is "I am the neighbor of dr x and I am sure he called up here to have you......" but I was getting vestibular testing and already shrank down her pHD so why add injury to insult

 

[doctalaughs]

Interesting thread. I'm not in EM (I'm a specialist) but the same problems are occurring in all areas of medicine.

The thing is, I'm fine supervising a mid-level. I'm also fine taking responsibility for any patient I was consulted about. However, in cases where the mid-level didn't ask a thing, and didn't come for help, why in god's name are we responsibly legally? It's insane IMO. Especially in places where the hospital hired that mid level with little input from me? Even if I did hire that person - they make their own decisions; there is NO way I can prevent them from screwing something up, even if I think they are a "well trained" mid-level provider. If something complex is missed each provider should be responsible for their own decisions. Since mid-levels aren't going away the law should change in that respect. And there are fewer and fewer places you can work as a physician without supervising a mid-level, so it's less of an option to opt out.