Advanced Practice Nurses in ICUs

[sevo85288]

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Can anyone comment on their role in the ICU. Lines, vent mgmt, how much freedom, scope of practice. Thanks

 

[bulgethetwine]

Can anyone comment on their role in the ICU. Lines, vent mgmt, how much freedom, scope of practice. Thanks

Worked with a guy who was full-time in the CT-ICU, dude even did central lines. He was great. Excepting him, though, the vast majority I've worked with function at about the level of a PGY-1.5 which is to say, then can collect data, but not reliable for procedures or anything comprehensive. Even the experienced ones struggle with the nuances of multi-organ dysfunction.

I wouldn't let anyone touch the vent except for MD or RT (and if the MD does it, he/she better be involving the RT) cause I think there's synergy there.

With the on-going push for more autonomy by mid-levels, I'm becoming more resistant to inviting further NP/PA involvement in my unit. I'm tired of my colleagues selling out. I think residency and fellowship means something.



Sorry.

 

[NurseKJ]

Worked with a guy who was full-time in the CT-ICU, dude even did central lines. He was great. Excepting him, though, the vast majority I've worked with function at about the level of a PGY-1.5 which is to say, then can collect data, but not reliable for procedures or anything comprehensive. Even the experienced ones struggle with the nuances of multi-organ dysfunction.

I wouldn't let anyone touch the vent except for MD or RT (and if the MD does it, he/she better be involving the RT) cause I think there's synergy there.

With the on-going push for more autonomy by mid-levels, I'm becoming more resistant to inviting further NP/PA involvement in my unit. I'm tired of my colleagues selling out. I think residency and fellowship means something.



Sorry.

Bulgetthewine,

Legitimate question here... are you at all aware if NPs that you are working with one the unit/ED trained as FNPs (family np- read birth to death primary care) or are they ACNP (adult acute care- acute and complex disease management, ect)?

My state BON will only allow ACNPs to work on monitored patients, but other states will allow FNPs in an acute setting if they have the RN experience to back it up.

Just wondering your thoughts on this issue, as a physician ( attending? )... ( I was considering doing an ACNP program, but decided for FNP, so I have a personal interest in this topic).

To the OP, do you know if you will be with FNP/ANP (family/adult) vs ACNPs? It might (?) make a difference in their abilities... ?

 

[proman]

My experience with acute care NPs has been something I wish I could forget. They're very knowledgeable about specific management details or devices (ie VADs, or a surgeon's preference of when to pull chest tubes). The downside is that they think that translates to actual managing patients, which is disappointing for all.

 

[southerndoc]

The critical care PA/NP's at my hospital are pretty good from what I've seen in the ED for their workups. Most are trained on putting in lines. The intensivists work really hard to orient them and get them up to speed. Plus they get a lot of volume from us to keep them busy (we see 120,000 patients/year with a 20% admission rate).

 

[deleted6669]

our trauma icu also uses pa's. they admit and follow their own pts and discuss them at morning rounds with the attendings just like our md residents. they do full scope icu procedures( thoracentesis, central lines, chest tubes, etc, etc). also a busy place with high admit rate. level 1 trauma, etc

 

[bulgethetwine]

our trauma icu also uses pa's. they admit and follow their own pts and discuss them at morning rounds with the attendings just like our md residents. they do full scope icu procedures( thoracentesis, central lines, chest tubes, etc, etc). also a busy place with high admit rate. level 1 trauma, etc

Really?

There's a word for that: Malpractice

You think they really "admit" their own patients? No - there is a big difference between having admitting privileges and doing the paperwork when the attending makes the decision to admit.

I doubt they do "full-scope" ICU procedures. The guy I know who did central lines still did them under full supervision.

I suspect you're extrapolating from a situation where, really, the mid-level might occasionally do a procedure in a very stable patient, and that the mid-level probably is involved in those trauma patients who are essentially in an observation status for 24 hours.

If your paragraph above actually describes reality, it makes me sick that a so-called Level 1 trauma center would allow that just to save a few bucks. There is NO WAY their ACS certification would survive a review if that was the case.

I'm sorry. Residency and fellowship equips you to manage trauma patients, not PA school.

 

[PICUPNP]

As a NP in a large childrens hospital. we are fully staffed by NPs in the PICU. They admit patients, perform ALL procedures which includes lumbar punctures, central lines, art lines, intubations, chest tubes, etc. Most of these procedures were done WITHOUT direct physician supervision. In addition, the NPs and MDs manage vents from simple SIMV to APRV and High Freq Oscillatory Vents, and we DO make changes.
If you thinks its malpractice, talk with all of our intensivists and I think you'll find they feel differently.....

 

[deleted6669]

Really?

There's a word for that: Malpractice

You think they really "admit" their own patients? No - there is a big difference between having admitting privileges and doing the paperwork when the attending makes the decision to admit.

I doubt they do "full-scope" ICU procedures. The guy I know who did central lines still did them under full supervision.

I suspect you're extrapolating from a situation where, really, the mid-level might occasionally do a procedure in a very stable patient, and that the mid-level probably is involved in those trauma patients who are essentially in an observation status for 24 hours.

If your paragraph above actually describes reality, it makes me sick that a so-called Level 1 trauma center would allow that just to save a few bucks. There is NO WAY their ACS certification would survive a review if that was the case.

I'm sorry. Residency and fellowship equips you to manage trauma patients, not PA school.

by "admit there own pts" this is what I mean:
er provider calls ICU doc and says"mr. jones needs to be admitted for dka, etc"
ICU doc says" ok, I will have the pa come admit them"
pt is admitted to the service of dr xyz but the admission H+P and all procedures are done by the pa. the first time the icu doc sees them is next morning at am rounds. the pa follows them throughout their course, consults with the icu doc and other specialists as needed and follows them until they leave the unit.
new pa hires to the ICU go through an orientation process that lasts about 2 yrs with gradual increases in autonomy and scope of practice. they are not running their own pts with a high level of autonomy right off the bat.
some of the pa's attended critical care pa residencies that last 1-2 yrs after pa school before being hired. to see info on the residencies out there for pa's see www.appap.org

this is an overview of the pa critical care residency at hopkins:

Modeled after the surgical MD resident program, you will follow similar schedule call requirements as the surgical and/or Anesthesia residents within the ICU. You will work closely with the existing ICU Physician Assistants and Nurse Practitioners. This relationship facilitates the intense mentoring and collaboration that is required for your growth and development in surgical, medical, and critical thinking skills.

Rotation schedules have been organized to provide the most educational and supportive environment in which to learn.

Intensive Care Unit Rotations may include but not be limited to the following:

* General Surgical ICUs – includes trauma, transplant, vascular, oncology, craniofacial, orthopedic, hepatic, pancreatic, thoracic, endocrine, plastics, and other surgical patients
* Burn ICU
* Pediatric ICU
* Neurosurgical ICU
* Cardiac ICU
* Medical ICU

Residents will also have an elective rotation which could include repeating of an ICU rotation or time on a surgical or specialty service – these will be personalized for each resident. Suggestions include:

* Infectious Disease
* Renal
* Cardiology
* Palliative Care
* Radiology

Didactic opportunities include:

* Core lectures in Intensive Care
* Surgical/Anesthesia Grand Rounds
* Morbidity and Mortality Rounds
* General Topics in Surgery and Anesthesia
* Intern and Resident conferences
* Weekly Residency Lectures
* Simulation Center sessions - brochoscopy, central line placement, simulated patients and scenarios
* Core Policy and Safety Modules
* Leadership Modules
* FCCS/ACLS/PALS courses

 

[eddoc03]

Sorry if it offends you, bulgethetwine, but emedpa is spot on. The PA's in our critical care units do it all and, perhaps because they have all been at it awhile, do it quite well.

 

[deleted6669]

Sorry if it offends you, bulgethetwine, but emedpa is spot on. The PA's in our critical care units do it all and, perhaps because they have all been at it awhile, do it quite well.

Thanks for the md confirmation.
( see, I wasn't making it up...)

 

[southerndoc]

Thanks for the md confirmation.
( see, I wasn't making it up...)

Nope, you aren't making it up. Our critical care PA's do central lines without supervision (the ones who have done enough to be checked off).

 

[notinkansas]

In my city, 4 hospitals, most ICUs are pretty much run by midlevels. Attendings round during day, but then go home (available by phone). Midlevels do all procedures (lines, chest tubes) and manage vent (actual physical changes done by RT, decision on what to change made by midlevel). Midlevels are alone in the ICU at night. Total ICUs covered this way: 2 SICU, 2 CTICU, 1 trauma ICU, 2 mixed ICU (smaller hospitals, least sick pts) one SICU and trauma ICU also has residents rotating (surgery, anesthesia and EM residents) and there have been conflicts over who is in charge and who does procedures. Most of the midlevels have been doing it a while, and I think they usually do a good job. I just think it's a bit of a problem that there is so little physician involvement, especially since I believe it conflicts with resident education. There have been instances of residents finishing ICU rotation but not feeling comfortable with lines. That's a problem and I thin there is a risk of creating a generation of physicians who aren't comfortable with these procedures. And I don't think that's OK.

 

[poresofkohn]

As a NP in a large childrens hospital. we are fully staffed by NPs in the PICU. They admit patients, perform ALL procedures which includes lumbar punctures, central lines, art lines, intubations, chest tubes, etc. Most of these procedures were done WITHOUT direct physician supervision. In addition, the NPs and MDs manage vents from simple SIMV to APRV and High Freq Oscillatory Vents, and we DO make changes.
If you thinks its malpractice, talk with all of our intensivists and I think you'll find they feel differently.....

>
It's been my experience that NP's have a marginal understanding of mechanical ventilation.

 

[NYRN]

I see the NP/PA role in an ICU as a win/win for MD's and NP's. Doing to lines and procedures will get old after the first year for a resident. The NP's and attendings know that the residents need a certain number of procedures, and that should be taken into account when the need for a procedure comes up.

If the NP is working in a surgical ICU, this frees up the resident so they can spend more time in the OR rather than taking care of tasks in the unit or on the floor.

In MICU and CCU, the fellow will be running around all day long doing consults and may not be in the unit as much as they need to be. If the NP can help the fellow out with certain tasks, I'm sure they will appreciate it.

In all ICU areas, the residents will need to attend conferences, lectures and that kind of thing. The NP's will take the workload off them so that they are able to attend to these important things. Perhaps, the resident will get to sleep for more than an hour during call. If the NP can take care of certain issues during the night where the resident/attending only needs to be called if the **** hits the fan or the NP isn't sure how to handle a situation, I'm sure the resident would appreciate that.

The NP's main function in the ICU setting is to help carry out the plan of care as created by the attending, not to take over the ICU.

 

[lushmd]

...The NP's main function in the ICU setting is to help carry out the plan of care as created by the attending, not to take over the ICU.

Famous last words. This is how "midlevel creep" starts. Although, by the sounds of it, midlevels have a much more extensive role in at least some ICUs than I expected/consider appropriate.

 

[NYRN]

Famous last words. This is how "midlevel creep" starts. Although, by the sounds of it, midlevels have a much more extensive role in at least some ICUs than I expected/consider appropriate.

I think its pretty far fetched to say that NP's/PA's are going to "take over" ICU's. Many procedures done in an ICU are routine. MD's are not in charge because they do procedures. You can train a tech to put a central line in. What makes the MD the primary decision maker is the plan of action not the procedures they do.

 

[Paseo Del Norte]

>
It's been my experience that NP's have a marginal understanding of mechanical ventilation.

Meh, concepts such as flow, total cycle time, inspiratory time, plateau pressures, graphics and so on are rather overrated IMHO. Why not just put em all in SIMV with 10 of PS and call it good? All that other fancy stuff is unimportant. 😀

 

[jdh71]

Meh, concepts such as flow, total cycle time, inspiratory time, plateau pressures, graphics and so on are rather overrated IMHO. Why not just put em all in SIMV with 10 of PS and call it good? All that other fancy stuff is unimportant. 😀

why not?

probably because SIMV is bull****

do you have any other suggestions?

 

[lushmd]

MD's are not in charge because they do procedures. You can train a tech to put a central line in. What makes the MD the primary decision maker is the plan of action not the procedures they do.

I agree with this sentiment entirely. Unfortunately, as seen in other areas of medicine, this doesn't prevent mid-levels from feeling otherwise and pressing for increased/independent scope of practice. Its a slippery slope.

 

[Paseo Del Norte]

why not?

probably because SIMV is bull****

do you have any other suggestions?

I hope you caught my sarcasm?

 

[jdh71]

I hope you caught my sarcasm?

I didn't.

My bad.

 

[NYRN]

I agree with this sentiment entirely. Unfortunately, as seen in other areas of medicine, this doesn't prevent mid-levels from feeling otherwise and pressing for increased/independent scope of practice. Its a slippery slope.

I think any mid-level (or even non-CC trained MD) who thinks they can take a job in the ICU and take over the position of a fellowship trained CC/Pulm MD is kidding themself. On one of the nursing websites, a study was done of currently licensed acute care NP's, and one of the things that was mentioned was years of experience in ICU before becoming an ACNP. The average was 15 years. I am willing to bet that someone who was a nurse for 15 years before knows thier limits more than a brand new NP/PA with no experience who "doesn't know what they don't know".

Where I work now, I work with a group of attendings and fellows in a certain specialty. The program director who has been practicing for over 25 years is a great teacher to the fellows and even to the nurses who want to learn. EVERY SINGLE DAY for the nearly 2 years I have been in this area, he teaches me something new. There is no way in any way shape or form, I am going to learn all there is to know in NP school and doing an NP fellowship in this area. Believe it or not, the overwhelming majority of NP's share this view. The NP's seeking total independance are focused on primary care, not specialty areas.

 

[bulgethetwine]

Famous last words. This is how "midlevel creep" starts. Although, by the sounds of it, midlevels have a much more extensive role in at least some ICUs than I expected/consider appropriate.

Couldn't agree more.

Probably another reason why care is much better IMHO in academic centers where mid level creep isn't as bad as in the community.

Residency and fellowship has value. And "mid-level creep" disrespects that. I, for one, am happy to forgo a little sleep and work a little harder in exchange for keeping mid-levels out of my unit, and KEEPING MY PATIENTS SAFER.

 

[Paseo Del Norte]

I didn't.

My bad.

No worries, I thought poresofkohn would appreciate the humour. With a name like that, he has to be a RCP.

 

[poresofkohn]

No worries, I thought poresofkohn would appreciate the humour. With a name like that, he has to be a RCP.

Guilty as charged😀
I did appreciate it, your sarcasm wasn't wasted on me! lol

 

[BSN2DOC]

As an RN working in a moderate sized Level I PICU, I would be hesitant to work in an ICU with midlevels running the service. I have met a few different RN's who definitely have the experience and knowledge base to manage nearly every type of patient that presents to our PICU. In fact, there are a few nurses that work on our unit who can run circles around a few of our intensivits... those nurses are rare though. Could I manage certain patients? Absolutely.

However, I agree that most critical care units should be managed by physicians who completed a residency and fellowship. I am obviously a proponent for the nursing profession and for mid-level practitioners, but I think there should be a limit. Certain aspects of medical care should be left to trained and qualified physicians.

 

[jl lin]

Meh, concepts such as flow, total cycle time, inspiratory time, plateau pressures, graphics and so on are rather overrated IMHO. Why not just put em all in SIMV with 10 of PS and call it good? All that other fancy stuff is unimportant. 😀

I do hope your grin means your are just kidding; b/c you can't do that; especially with kids.

 

[jl lin]

As an RN working in a moderate sized Level I PICU, I would be hesitant to work in an ICU with midlevels running the service. I have met a few different RN's who definitely have the experience and knowledge base to manage nearly every type of patient that presents to our PICU. In fact, there are a few nurses that work on our unit who can run circles around a few of our intensivits... those nurses are rare though. Could I manage certain patients? Absolutely.

However, I agree that most critical care units should be managed by physicians who completed a residency and fellowship. I am obviously a proponent for the nursing profession and for mid-level practitioners, but I think there should be a limit. Certain aspects of medical care should be left to trained and qualified physicians.

I have worked in a few centers that do all of what has been shared above, and one is a children's hospital. I will not name it though. I will say that there are always intensivists and other physicians around that keep their eyes on things. People generally know you have to be pretty careful, especially with kids. Rounds are at least twice a day, with constant follow-ups are done in terms of plans, changes, and evaluttion of effects.

Now the other huge children's hospital I worked in does not use PAs and NPs as much in the same way. But the nature of that particular institution is much more pro-medicine or shall I say more tightly controlled divisions. It hasn't stopped them from having some major lawsuits d/t unsafe practices within their own--medicine; BUT to be FAIR, I haven't worked in or seen an institution that did not have some lawsuit issues at one time or another. And trust me; I have worked in many.

Personally, though some fellow nurses may get miffed at me, I've had more positive and productive discussions and clinical work-flow and progression with physicians than with NPs. I guess really it ultimately depends on the individual people you are working with. But those that are more experienced and IMHO truly well educated about something, and that have a sense of humble confidence and are there for the patients, they are always best to work with--and you get better outcomes. I have been ridiculously stonedwalled by NPs, whereas insightful residents, fellows, or physicians see the particular point of view and work more with me in moving the patient forward.

If you stick with the facts and leave other nonsense out of it, things move a lot better. I don't mean to make it a male-female things, but honestly in certain ways I think more like, well, males are conditioned by society to do. What I mean by this is for example, clinically we need to look at all the facts in perspective and not get stuck on one thing, and then leave the other silliness or emo stuff out of it. YES. I know there are plenty of female physicians. And I am NOT speaking against my gender. I postulate that it is a cultural, sociological dynamic--women are generally allowed with groups in society to let emotions influence decision-making, whereas men are taught early on, even in terms of being on sports teams, that they are not to do that.

Women that enter male-dominated fields often have to adjust the socially tolerated approach to things. The appeal or focus on the emotionals aspects will not be easily accepted in the male-dominated areas. And when and where this makes since, it can be a very good thing. Whether MarySue doesn't like LindaJane should not have even a subconscience bearing upon decisions that are to be more objective-based in nature. I won't address how much of these dynamics are of some inborn nature or not; b/c I really addressing the sociological dynamics more than anything else. And clearly women can and do have a clear capacity to look at things more objectively. The issue from my perspective is have their been supported and raised in the culture to do this, or has the culture taught them that it is acceptable to do something else?

I mean it would be even clearer if we were talking of what is going on in some science lab at the bench; but when we are talking about the applicational science, things can and do get blurry. And I also think in critical care, if you are truly there for the patient you will tend to look more at the facts and the presentations, and then look at all factors in balance. It is amazing what people allow to get in the way of clear and balanced thinking.

So, No, it's not a totally male or female thing. I have seen plenty of males let all kind of ridiculous, prideful, and emo things get in the way of being more objective and balanced; but in general, if they have been raised with a lot of male influence and in a male-dominanted profession, they will suppress this.

I am just saying that possibly for cultural reasons or for some reason, having worked in a primarily female dominated profession, I will tell you that my assessment of the situation there is that those that often dominate nursing can let other dynamics get in the way of balanced decision-making. And it is why females to other females don't tend to handle conflict well. They do passive-aggressive stuff, or the out and out attack, but they don't think it is important to learn bonafide conflict resolution. It doesn't have to be that way; I think it is something that has been allowed to go on culturally speaking with women in our society. It's the "mean-girls" kind of mentality. Yes I know that there are men that have it; but it is discouraged more among their male peers and colleagues and higher-ups, in general.

But it is also the level of education and support, clinically speaking, that physicians get in comparison. Whatever you want to make of it, I have had more success and productive experiences working with physicians than with nurses or NPs. I have to withhold comment on PAs, b/c in the areas I've worked, well even though it's been a lot of different places, I can't really remember working with that many PAs. But to be fair, mostly in the critical care areas I've worked with intensivists, ologists, surgeons, physicians. It does suck to work with anyone that is stuck on some kind of trip though. What a waste of life and energy that is.

 

[Paseo Del Norte]

I do hope your grin means your are just kidding; b/c you can't do that; especially with kids.

I thought it was already well established that my post was sarcastic and more of a joke aimed at a respiratory therapist?

 

[poresofkohn]

I do hope your grin means your are just kidding; b/c you can't do that; especially with kids.

Capital U.
Capital G.
Capital H.

 

[bulgethetwine]

In fact, there are a few nurses that work on our unit who can run circles around a few of our intensivits...

However, I agree that most critical care units should be managed by physicians who completed a residency and fellowship. I am obviously a proponent for the nursing profession and for mid-level practitioners, but I think there should be a limit. Certain aspects of medical care should be left to trained and qualified physicians.

"... most critical care units should be managed by physicians who completed a residency and fellowship"

Er, how about all?

While your post (kind of, in a back-handed sort of way) supports the merits of residency and fellowship your comment that "a few nurses that work on our unit .... can run circles around a few of our intensivists" is laughable.

Haha

But it's not your fault. It's because you've never been to medical school. Or completed residency. Or completed fellowship.

 

[jl lin]

Capital U.
Capital G.
Capital H.

Keeping w/ the puerile in your reply:

Capital L.
Capital S.
Capital R.

 

[jl lin]

"... most critical care units should be managed by physicians who completed a residency and fellowship"

Er, how about all?

While your post (kind of, in a back-handed sort of way) supports the merits of residency and fellowship your comment that "a few nurses that work on our unit .... can run circles around a few of our intensivists" is laughable.

Haha

But it's not your fault. It's because you've never been to medical school. Or completed residency. Or completed fellowship.

Don't think that is what the person is saying. And your last comment was clearly condescending. It's ridiculous to get into pissing matches. If you think every physician is super sharp and on the ball over ALL nurses and NPS and PAs, who have picked up on imporant things that those physicians have missed, you are NOT living in reality.

We AGREE, as have I over and over and over that medical school and the residency medical system gives much better education and preparation overall. But what you are missing in the individual factor, and that which grows clinically based on experience. That is up to the individual person. DO NOT even try to NEGATE the clinical insights of people that have gained great experience and understanding into particular issues. It's silly. It is weak, and what's more, it equates to nothing more than some juvenille pissing contest. Wsdom and maturity need to be the voice of reason here, especially in light of the fact that NO ONE is trying to take over medicine for the love of God.



Once more, medicine has MUCH bigger concerns that this spagettified fear of "midlevels."

When a person keeps beating a drum on something that is essentially a non-issue, in light of the fact that there are much bigger, "Titanic" issues where the focus must be, one has to wonder what is with the fixation.

No one wants NPs or PAs or DNPS or non-physicians taking over. Stop imagining that the sky is falling over this issue. It is not. It's just NOT realistic, period.

 

[bulgethetwine]

Don't think that is what the person is saying. And your last comment was clearly condescending. It's ridiculous to get into pissing matches. If you think every physician is super sharp and on the ball over ALL nurses and NPS and PAs, who have picked up on imporant things that those physicians have missed, you are NOT living in reality.

We AGREE, as have I over and over and over that medical school and the residency medical system gives much better education and preparation overall. But what you are missing in the individual factor, and that which grows clinically based on experience. That is up to the individual person. DO NOT even try to NEGATE the clinical insights of people that have gained great experience and understanding into particular issues. It's silly. It is weak, and what's more, it equates to nothing more than some juvenille pissing contest. Wsdom and maturity need to be the voice of reason here, especially in light of the fact that NO ONE is trying to take over medicine for the love of God.



Once more, medicine has MUCH bigger concerns that this spagettified fear of "midlevels."

When a person keeps beating a drum on something that is essentially a non-issue, in light of the fact that there are much bigger, "Titanic" issues where the focus must be, one has to wonder what is with the fixation.

No one wants NPs or PAs or DNPS or non-physicians taking over. Stop imagining that the sky is falling over this issue. It is not. It's just NOT realistic, period.

It's not ridiculous when you see what some members of the nursing community (maybe not you) are trying to lobby for, and what some hospital administrators will accept to save a buck.

So I wouldn't characterize it as "no one".

It's disgusting, and the current trend of de-valuing residency and fellowship is dangerous to patients. Don't try and be an apologist for some of your more aggressive colleagues by trying to make it sound like you're attention is focused on the "titanic" issues.

Besides, no one has addressed this yet, but your convenient line of "individual experience" actually doesn't hold up when you consider that your "experience" is 36 hour work weeks taking care of 1-2 patients a shift in the unit, and mostly technical stuff at that.

Puhleeeeeze.

 

[jl lin]

It's not ridiculous when you see what some members of the nursing community (maybe not you) are trying to lobby for, and what some hospital administrators will accept to save a buck.

So I wouldn't characterize it as "no one".

It's disgusting, and the current trend of de-valuing residency and fellowship is dangerous to patients. Don't try and be an apologist for some of your more aggressive colleagues by trying to make it sound like you're attention is focused on the "titanic" issues.

Besides, no one has addressed this yet, but your convenient line of "individual experience" actually doesn't hold up when you consider that your "experience" is 36 hour work weeks taking care of 1-2 patients a shift in the unit, and mostly technical stuff at that.

Puhleeeeeze.

Sigh. . .


Really, it's not going anywhere. People can lobby all they want.


Now, as to my experience, you sir or maam have ABSOLUTELY NO idea what it entails. Just as I agree that I don't know all of what yours entails.

When you work in this industry, if you will, long enough, you will see that quite often it's not the SUIT BUT THE PERSON IN THE SUIT THAT MATTERS.


We agree that medical education and residencies should not be undermined. I agree that the preparation is better, and that so called "midlevels" shouldn't be taking charge in medicine.

There is NO ARGUMENT here! Are you seriously going to get bent out of shape every single time some yahoo or yahoo group goes into lobby-mode? Come on already.



You might be stuck on this out of some need to negate and undermine any clinical perspectives from others, which you feel you have some right to condescend to. If so, that is a HUGE mistake, and it will only end up hurting you, your profession, healthcare, and the patients.

Get over this ridiculous fixation.

Do you actually think, for example, that I believe I know more about emergency medicine b/c I initially suggested the diagnoses of leukemia in my dad while others totally diregarded the CBC and focused on an GI bleed instead??? It was by my request the attending ED physician called in the hemonc people. And guess what? Dad's marrow was filled with blasts. Was it a lucky guess on my part? NO. It was NOT. I pointed out the pancytopenia and other issues of concern. But I gained that insight, in part, from many years of working with excellent physicians in critical care, and b/c of my nature to sift and inquire. This is one small sampling of experiences that I could share with you.

BUT HELL NO. I don't think I know more than that ED physician. . .AT ALL. I came in concerned and focused on one patient, my dad. He was juggling MANY PATIENTS.

But your either/or, "us versus them" mentality helps no one, least of all the patients or healthcare team dynamics. And it sets a bad example for other physicians or soon-to-be physicians. For they soon will come think such condescension is an entitlement for having a MD. Lord, I hope not. Healthcare has enough problems right now.

Fortunately that ED physician was quite secure in who he was. He was very supportive and He NEVER, NOT ONCE, condescended to me. In fact, he respected my experience and the idea that indeed I had some clinical insight beyond the GP or even beyond a first or second year med student--b/c of my clinical work--and the kinds of patients in my care over the years in critical care.

You must know by now, espeically in critical care, one resident, fellow, or doctor cannot look at all aspects of everything at every moment, for he or she has many critical patients and ED admits to evaluate and deal with. Who the hell do you think is there combing over everything in the ICU? I will tell you; it is the intelligent, committed, and hypervigiliant critical care RN.

Now if you want to try to play that down, you go right on ahead. And I agree completely that it doesn't make a physician, and I for one have NEVER, EVER said or ACTED as if it did.

But you are dead wrong when you try to undermine my experiences. And I will be damned if I will have a non-productive pissing contest with you about it.


You just go on ahead and disrespect people and their experiences and insights--even in light of this imaginary take over of medicine. Common sense alone should tell you that is it the furthest thing in the world from reality. But you want to keep harping on this, claiming that it's not overstated.
Please show me numbers in terms of displaced physicians by NPs or PAs. I beg you to show me how physicians are being run out of practices everywhere b/c of this massive takeover by NPs or PAs. It's ridiculous, and you know it is.


You will also be surprised at how many of us critical care RNs have and do work over 50-60 hours per week--not including doing so while we raise families and continue our own educations. Puhleese my ass. Get over yourself already.

If you had any insight into this, you'd consider that an advantage in critical care nursing in terms of learning is that you can focus in on a few very sick patients at a time. It affords the interested critical care nurse the opporutnity many times to delve in deeper with what is going on with certain kinds of client diseases, conditions, and complications. The technical stuff is something a monkey can learn. And any RN can learn the basic "safe" parameters for say gtt titrations. Not all of them can tell you the whys and how of it; for some don't have enough understanding of hemodynamics to know this. Some nurses don't go further than technical mode. Others like me that have always been interested in disease dynamics on the human body and various responses to treatments and so forth. So we learn more--we seek it out b/c it greatly interests us. And the great thing in many of these university settings is there is less egomania and people are encouraged to teach and learn from each other as part of a team. I have had more residents and fellows encourage this enhanced understanding than I have time to share. People can tell when others truly want to understand things and grow, and when physicians AND nursing are really totally there for their patients.

No offense, but please get over yourself. You don't know what you are talking about in this regard--with certain nurses and their experiences. It is unfounded. It's this very attitude that keeps people on the level of technicians, and that is something that sadly some physicians want. In fact they prefer technicians, b/c they aren't into the big picture or the whys and why nots, they are cheaper, and they genuflect in the physician's presence. Secure physicians don't need people to bow down and kiss their arses.

You know, you might be surprised how we agree on some things--Paul Marino for one. This "us versus them" mentality promotes unnecessary stress and contention in healthcare. It's really uncalled for.

Stop worry so much about other disciplines and worry about enhancing your own, starting with YOU.

 

[bulgethetwine]

You must know by now, espeically in critical care, one resident, fellow, or doctor cannot look at all aspects of everything at every moment, for he or she has many critical patients and ED admits to evaluate and deal with. Who the hell do you think is there combing over everything in the ICU? I will tell you; it is the intelligent, committed, and hypervigiliant critical care RN.

Now if you want to try to play that down, you go right on ahead. And I agree completely that it doesn't make a physician, and I for one have NEVER, EVER said or ACTED as if it did.

Most of your message talked about an RN doing exactly what they should do when functioning as an RN in the unit.

That was spot on.

It's the idea that somehow being a great RN will translate into the ability to be the sole provider in an ICU in the middle of the night.

That's what some of your colleagues, believe it or not, are trying to argue for. And that's what I'm against -- I'm not against having skilled, experienced nurses (in fact, it's an absolute requirement for me to be able to do my job) doing exactly as you describe in your message.

 

[jl lin]

Most of your message talked about an RN doing exactly what they should do when functioning as an RN in the unit.

That was spot on.

It's the idea that somehow being a great RN will translate into the ability to be the sole provider in an ICU in the middle of the night.

That's what some of your colleagues, believe it or not, are trying to argue for. And that's what I'm against -- I'm not against having skilled, experienced nurses (in fact, it's an absolute requirement for me to be able to do my job) doing exactly as you describe in your message.

Bulge, that is totally putting words in my mouth and in the mouths of a number of nurses, even though I know you wrote "some colleagues." Still, let me be clear. Never, NOT ONCE did I say it 'translates into being a sole provider in the ICU in the middle of the night,' or any other time of day for that matter.


What I am saying is that you seem to be prejudging the long-term, culmulative clinical experiences of some nurses.

I NEVER, EVER want to see anyone, including bean-counters or administrators totally running EDs, ICUs, etc. Only bonafide, experienced, knowledgeable, and caring physicians should be running these places, PERIOD. I will do everything in my power to speak to this; but again, it well may be that this is overstated as an imminent problem.

I mean if you go along these boards people have others totally convinced that PAs and NPs or DNPs are on the verge of taking over medicine. To me, as a profession, this indicates that some within it completely underestimate medicine's longstanding power and influence.

Now I don't go along with that b/c I simply must yield to the biggest power. I'm too independent-minded for that. I go along with physicians at the helm, b/c their education and clinical "rearing," if you will, makes them the best candidates for this, hands down. As I said in other threads, and perhaps this one as well, this is totally a no brainer.


But I will also say, if you are going to take this tough position against NPs and say CRNAs, etc, then you need to take the same tough position against PAs and AA's etc. You can't have it both ways, and you really shouldn't.

If you allow PAs, then you have to allow NPs. If you allow AAs then you have to allow CRNAs. Don't favor one over the other with the idea that you will be able to control one group over the other. In time, you will not. You will be dealing with the exact same issue you have with regard to nurses, and truthfully, medicine has more history working with nursing than any other group.


You have to understand that there has been this ongoing animosity against nursing for some time. Now I know why I have some issues with nursing, but that is b/c I've worked in the field for a long time. I know quite well where nursing's major weaknesses are. But if the true underlying basis for the tension is that nursing is at least ideally supposed to be largely about patient advocacy, whereas that may well not be the case with other allied health disciplines, then there is a serious problem with the underlying reason for the tension. For really, all in healthcare in my opinion should be advocates for patients.


I think someone needs to get to the core of what this is really all about.



Honestly, I belong to organizations that promote advanced practice nursing and expanded education, and I currently attend a university where all that teach are really in one way or another advanced practice and do research. Truthfully, I am not getting this sense of takeover of medicine. There is outspoken respect for medicine as much as for nursing, and in my experience, even many years ago when I went to college for nursing, there has always been strong admonition against overstepping into medicine.

Nursing is a different discipline. The art and science of nursing is much different from that of medicine, even though there are areas of overlap.

Nursing is patient focused, and thus more holistic in nature. Medicine is more disease-focused. But that is NOT to say that many excellent physicians are not truly holistic in their practice.

Nursing is more concerned with patient responses and needs. Medicine is more concerned with core physiological conditions that are at play. But this is not to say that nurses can't and don't learn physiology and pathophysiology as well.

It has to do with the amount of time you spend focusing on what. Part of my frustration in nursing is that I am focusing on all these other things, but my mind is still cuious and focused on what is going on physiologically and how the body is responding to treatments X and Y.

Good nurses tend to make good case managers for patients. This is something I have done and enjoyed doing to help patients, but it is not my love. It's not how my mind wants to work first and foremost.

And this is why I have loved critical care so much, b/c even though it can get crazy at times, I can think and consider physiologically what is going on with the patient. Unfortunately, the numerous demands of nursing pull you away from that to manage so many other things--thus you are juggling interactions with other disciplines as well as focusing on many of the patients' and their families' needs. If that is fulfilling enough for a person as a nurse, I say that I know darn well it's wonderful. Fine. If it is not, at times it gets to be totally frustrating--b/c your mind as a nurse --or at least my mind--is alway moving back to the patient's physiological dynamics and evolving status.


Forgive my digression.




But I really do believe that most nurses, advanced practice or not, have NO desire to take over medicine.

CRNAs that think they replace ologists are arses. Frankly, no offense to them, but I think a correction in the field would be good for some of them. And NO ONE has been more irritated and offended with working with critical care nurses that simply just want to get their year done in the unit so that they can use that to help get into a nurse anesthetist program than me. Many of my colleagues and I find this beyond irksome.

But here is something that I definitely know needs to be qualified. Nurses are NOT technicians, even if they are involved in the technical fx of some things. This is not the art and science of nursing. Whatever you may know or feel about the nursing theorists, one thing is true. So much in their various writings can demonstrate why nursing should not be viewed as merely technological, just as medicine should not be.

Dorothy Orem, for example, set out a system of thinking regarding nursing care, a paradigm, where the patient's need to develop the facilitation of self-care is paramount. And if a number of nurses had heeded some of her perspectives, they would find they would helping more patients in terms of becoming partners in their healthcare and wellness, rather than needy codependents that sometimes comply and other times do not!

The effects and details of various medical txs may indeed become part of the nursing process, but predominately it focuses on the patient or familiy in helping to faciliate their own wellness according to their needs and responses.

And this is part of why nursing diagnoses are so different than medical diagnoses, even though the nurse must know what the various medical diagnoses must mean and what they may entail.

Primarily nurses are dealing with individual human responses to illnesses. But this loss of understanding, I think, is part of the problem. Some in nursing and in advanced practice nursing have forgotten what the the art and science of nursing is about. They see the theorists as mere Ivory Tower Idealists. While this might be easily argued for some, could it be fairly stated of say, Florence Nightengale, who suffered, worked, and gave up much for this art and applied science of nursing? I don't think so

Below is a bit of Dorothy Orem's view on nursing:

[Orem sees nursing as "an art through which the practitioner of nursing gives specialized assistance to persons with disabilities of such a character that greater than ordinary assistance is

necessary to meet daily needs for self care and to intelligently participate in the medical care they are receiving from the physician" (Orem, cited in McLaughlin-Renpenning, 2002). Nursing consists of actions deliberately selected and performed by nurses to help individuals or groups
under their care to maintain or change conditions in themselves or their environment. (Orem,1985, cited in Meleis, 1997).]​

Someone was right in saying that those in nursing that step so far outside their boundaries into the discipline of medicine do nursing a great disservice as well--and this ultimately affects the patients and families, b/c NO ONE can do it all.​

But here it is. Really Bulge, so many in nursing appreciate the differences and are fine with them. ​

People have to find productive ways to respect each others' work and boundaries. The divisive mentality only adds more insult to an already troubled healthcare system.​

Also, what does this mean? "Don't try and be an apologist for some of your more aggressive colleagues by trying to make it sound like you're attention is focused on the "titanic" issues."​

Uh, what?​

I have NOT by far been an apologist for their position, if it is indeed to the extreme that many suggest. An apologist takes a position of defense for something--as in apologia. . .?. . . I have far from taken a defense--supporting some belief on issues regarding DNPs and taking over medicine. My apologia has been quite the opposite.​

I am sensing something more than some fear of "midlevel" domination. I think we all really know that it isn't and won't go far. For those that don't, they don't get how the current system works.

See, physicians are seen as bringing in revenue; whereas nurses are seen as merely prevention for loss of revenue--thus, they are seen more as an expenditure.

Nursing schools are not supported by the huge pharmaceutical companies, and they have no such great monolopolizing power, as physicians have long held in this nation. I respect physicians, but I must be completely honest if we are going to continue on with this "hyper-fear" position on "midlevel domination."​

The Titanic issues should be completely obvious to you if you are a physician.

The fear of "midlevel domination" is not a Titanic issue. The fear of DNPs is not either. They will hold their ground pretty much in the academic setting, period.​

 

[lushmd]

Residency and fellowship has value. And "mid-level creep" disrespects that. I, for one, am happy to forgo a little sleep and work a little harder in exchange for keeping mid-levels out of my unit, and KEEPING MY PATIENTS SAFER.

Totally agreed.

A few thoughts (in no particular order):

(1) What's this stuff re allowing PAs/AAs but not NPs/CRNAs? By virtue of their training, they have largely similar roles (i.e. are permitted to do similar things) but AFAIK the PAs/AAs aren't pushing for independent practice (as the NPs/CRNAs are). I doubt anyone would mind if NPs/CRNAs were content to work under physician supervision (the fact they are apparently not is why some may take a "tough position" as you say against them; likewise if PAs/AAs sought independent practice we'd see a similar reaction). So I'm not sure where this is coming from.

(2) Re the "holistic" nature of nursing: Obviously, physicians and nurses receive very different training. Having said that, to think that physicians perceive pathophysiologic processes to the exclusion of the rest of the patient is a myth. In fact, both med schools and residency programs are placing increasing emphasis on this aspect of patient care.

(3) Along these lines, let's move on "patient advocacy." This is a role that, for some reason, many nurses want to claim as their exclusive domain. Frankly, I'm not sure why. As a physician, I certainly want what's best for my patient too (ideally obtained in as quick and drama free manner as possible).

(4) Re medical student education being funded by pharmaceutical companies: I assume you're referring to this report (or others like it). Please recognize that there is a big difference between a medical center receiving funding and that money being used to pay for medical education directly. Given that average medical student debt is over $150K for four years, I'm comfortable in assuming that most of us payed for our education directly. Now, its certainly true that medical centers receive a portion of any grant money awarded to faculty members (including grants from drug companies) in the form of indirect costs. Having said that, most medical centers that have med schools also have nursing schools. And before you mention residency funding, realize that its covered by the government.

(5) Re the importance of allowing for individual experience: I'm all for individuals advancing their education and training. However, it doesn't make sense to say that you need to account for individual experience when we're discussing allowing a group of people to have increased scope of practice. Frankly, if an individual nurse is that bright/talented and wants increased responsibility, bite the bullet and go to med school and do residency/fellowship (I know a number of people who have done this).

(6) At the end of the day, we (physicians and nurses) play very distinct but important roles in health care. Although there is inherently some overlap, one cannot replace the other. Ideally, we all recognize this so we can more effectively work together in our defined roles. Frankly, I would like nothing more than to agree on this, shake hands, call it a day, and move on with more productive matters. Unfortunately, this seems unlikely as nurses continue to infringe on the practice of medicine. Yes, you'll likely continue to say that this is much ado about nothing. I submit that we have very different perspectives.

 

[Paseo Del Norte]

Is anybody else tired of hearing all the bloviation about how us nurses are the jedi masters of holistic care?

 

[bulgethetwine]

Totally agreed.

A few thoughts (in no particular order):

(1) What's this stuff re allowing PAs/AAs but not NPs/CRNAs? By virtue of their training, they have largely similar roles (i.e. are permitted to do similar things) but AFAIK the PAs/AAs aren't pushing for independent practice (as the NPs/CRNAs are). I doubt anyone would mind if NPs/CRNAs were content to work under physician supervision (the fact they are apparently not is why some may take a "tough position" as you say against them; likewise if PAs/AAs sought independent practice we'd see a similar reaction). So I'm not sure where this is coming from.

(2) Re the "holistic" nature of nursing: Obviously, physicians and nurses receive very different training. Having said that, to think that physicians perceive pathophysiologic processes to the exclusion of the rest of the patient is a myth. In fact, both med schools and residency programs are placing increasing emphasis on this aspect of patient care.

(3) Along these lines, let's move on "patient advocacy." This is a role that, for some reason, many nurses want to claim as their exclusive domain. Frankly, I'm not sure why. As a physician, I certainly want what's best for my patient too (ideally obtained in as quick and drama free manner as possible).

(4) Re medical student education being funded by pharmaceutical companies: I assume you're referring to this report (or others like it). Please recognize that there is a big difference between a medical center receiving funding and that money being used to pay for medical education directly. Given that average medical student debt is over $150K for four years, I'm comfortable in assuming that most of us payed for our education directly. Now, its certainly true that medical centers receive a portion of any grant money awarded to faculty members (including grants from drug companies) in the form of indirect costs. Having said that, most medical centers that have med schools also have nursing schools. And before you mention residency funding, realize that its covered by the government.

(5) Re the importance of allowing for individual experience: I'm all for individuals advancing their education and training. However, it doesn't make sense to say that you need to account for individual experience when we're discussing allowing a group of people to have increased scope of practice. Frankly, if an individual nurse is that bright/talented and wants increased responsibility, bite the bullet and go to med school and do residency/fellowship (I know a number of people who have done this).

(6) At the end of the day, we (physicians and nurses) play very distinct but important roles in health care. Although there is inherently some overlap, one cannot replace the other. Ideally, we all recognize this so we can more effectively work together in our defined roles. Frankly, I would like nothing more than to agree on this, shake hands, call it a day, and move on with more productive matters. Unfortunately, this seems unlikely as nurses continue to infringe on the practice of medicine. Yes, you'll likely continue to say that this is much ado about nothing. I submit that we have very different perspectives.

Best post I have read on this topic.

 

[Socrates25]

Sorry if it offends you, bulgethetwine, but emedpa is spot on. The PA's in our critical care units do it all and, perhaps because they have all been at it awhile, do it quite well.

If they can "do it all" then why the heck are we paying you a salary? Sounds like we are paying you for nothing if your PAs/NPs "do it all" as you say.

 

[Socrates25]

Nope, you aren't making it up. Our critical care PA's do central lines without supervision (the ones who have done enough to be checked off).

Why is everybody so impressed by central lines around here? I was doing them solo 5 months into my intern year (as was everybody else in my residency program). Most ICUs dont have any in-house attendings after a certain hour anyways, so in fact most if not all intubations and central line placements are going to be done by a non-attending after 5-6 PM.

 

[Socrates25]

As a NP in a large childrens hospital. we are fully staffed by NPs in the PICU. They admit patients, perform ALL procedures which includes lumbar punctures, central lines, art lines, intubations, chest tubes, etc. Most of these procedures were done WITHOUT direct physician supervision. In addition, the NPs and MDs manage vents from simple SIMV to APRV and High Freq Oscillatory Vents, and we DO make changes.
If you thinks its malpractice, talk with all of our intensivists and I think you'll find they feel differently.....

Actually I want the name of your hospital so I can talk to the intensivists to figure out why they are getting paid 200k if they arent providing any kind of valuable service worth of such a high income.

You should also notify your hospital CEO -- I'm sure he'd be upset by the fact that he's paying out $200k to a bunch of lazy scrub MDs who are contributing nothing to his ICUs. He could save a ****load of money by firing them -- after all they are getting paid for services not rendered and thats fraud in my book.

 

[bulgethetwine]

Actually I want the name of your hospital so I can talk to the intensivists to figure out why they are getting paid 200k if they arent providing any kind of valuable service worth of such a high income.

You should also notify your hospital CEO -- I'm sure he'd be upset by the fact that he's paying out $200k to a bunch of lazy scrub MDs who are contributing nothing to his ICUs. He could save a ****load of money by firing them -- after all they are getting paid for services not rendered and thats fraud in my book.

Hope you have your fire ******ants on - mostly on here are a bunch of NPs pushing for more responsibility and $$$ without becoming legitimate docs, and a bunch of apologists for their cause.

Good luck though (wink)

 

[tncekm]

Is anybody else tired of hearing all the bloviation about how us nurses are the jedi masters of holistic care?

Yes. Especially considering it's absolute nonsense.

 

[The right Path]

Hope you have your fire ******ants on - mostly on here are a bunch of NPs pushing for more responsibility and $$$ without becoming legitimate docs, and a bunch of apologists for their cause.

Good luck though (wink)

Really bulge?

The OP asked for opininons, experiences with NPs practicing in the ICU and got a variety of responses from various disciplines. Some having a generally good opinion/experiences working with NPs (and PAs) and others, not so much. Various posters have also stated a range of responsibility/autonomy of NPs (and PAs) in the ICU.

The responses of the (only 2) NPs on here were just stating what their practice involves- answering the OPs question. That is hardly an expression of pushing for more money or responsibility. In fact no one stated that. When others have posted that having NPs/PAs in the ICU takes some of the load off of the attendings and residents the response (not from you) is "uh, garsh, I guess we shouldn't be paying all that money for the useless docs since the 'noctors' do it all". Nice leap of logic there. Outlandish hyperbole doesn't score any points.

You've made your opinion on clear on the appropriateness of midlevels (NPs in particular) managing patients in the ICU. I get it, respect it, and have nooooo desire to argue with it. But don't insult everyone's intelligence by claiming the majority of the respondents to this post are NPs with an agenda.

 

[Socrates25]

That is hardly an expression of pushing for more money or responsibility. In fact no one stated that. When others have posted that having NPs/PAs in the ICU takes some of the load off of the attendings and residents the response (not from you)

You've made your opinion on clear on the appropriateness of midlevels (NPs in particular) managing patients in the ICU. I get it, respect it, and have nooooo desire to argue with it. But don't insult everyone's intelligence by claiming the majority of the respondents to this post are NPs with an agenda.

Spare us this nonsense please. I can cite a dozen articles minimum by all the relevant "advanced practice" nurse organizations that clearly state they desire autonomous, independent practice with no MD involvement whatsoever.

This constant BS of "the MDs are paranoid and are greatly overestimating our goals" has been exposed over and over again as a lie. YOUR OWN FREAKING NURSING ORGANIZATIONS HAVE OPENLY ADMITTED WHAT THEIR "MASTER PLAN" FOR "ADVANCED PRACTICE" NURSES ARE.

So, do you want me to post the links or what?

 

[The right Path]

Hope you have your fire ******ants on - mostly on here are a bunch of NPs pushing for more responsibility and $$$ without becoming legitimate docs, and a bunch of apologists for their cause.

Good luck though (wink)

Spare us this nonsense please. I can cite a dozen articles minimum by all the relevant "advanced practice" nurse organizations that clearly state they desire autonomous, independent practice with no MD involvement whatsoever.

This constant BS of "the MDs are paranoid and are greatly overestimating our goals" has been exposed over and over again as a lie. YOUR OWN FREAKING NURSING ORGANIZATIONS HAVE OPENLY ADMITTED WHAT THEIR "MASTER PLAN" FOR "ADVANCED PRACTICE" NURSES ARE.

So, do you want me to post the links or what?

That won't be necessary as that is NOT what I was referring to. Nice try though.

 

[bulgethetwine]

That won't be necessary as that is NOT what I was referring to. Nice try though.

Oh, I didn't say you were all NPs, right path.

I said lots of you (yes YOU) are apologists.

And not only the NP secret agenda.... how about the father of PA (Dr. Stead) and his plan for quackery: He details a plan that would allow midlevels to take a sort of correspondence based course over the internet, while being mentored by a physician. You can check out the details here

http://easteadjr.org/guest.html.

In essence it would allow midlevels to attain an MD degree without having to begin as an MS1. He sets forth various criteria, such as a minimum age of 27, a masters degree, --and perhaps most interestingly-- a required commitment to practice primary care in their home community.

Holy sh hilly ite, a fU truck King CORRESPONDENCE COURSE?!? Could you denigrate my training a little bit more?

All coated in happy campfire singing bulls hit about working in primary care even though this week it is revealed that mid-levels are now encroaching into specialty care!


Here's a thought - go back to undergrad. Get a degree with a high GPA. Write the MCAT. Ace the interview. Get through med school. Get a residency. Do a fellowship.

Then you get my respect.

Until then, you're just a nurse trying to grab responsibility and $$$$ to the detriment of my patients, all the while trying to take a short cut to what the rest of us worked pretty dam n hard to get to.

Apologist.