Advanced Practice Provider....but how and which one!?

[Splenda88]

I hope some states will accept FMG for the assistant physician license... and have them work under a physician license like PA. I will be the first one to support it.

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[Fiveoboy11]

It’s the ICU. They are all complicated and you shouldn’t be the decision maker on any of them as a midlevel. If you want to give ICU level care you really should become a doctor

No one should ever work independently in any setting so get over yourself. As an example to demonstrate this, physician's that work in the ICU are often incompetent with regard to physical therapy initiation or so called "orders." In other words my and my colleagues time is wasted left and right because some bonehead thinks they know everything.

 

[pamac]

I hope some states will accept FMG for the assistant physician license... and have them work under a physician license like PA

The optics of taking foreign physicians and making them vassals of physicians is awful. Besides, the same arguments and turf battles will emerge. So not only will the FMGs not be proud of their new role as PAs, the physicians won’t end up advocating for it. They have enough on their hands trying to maintain their clout in the face of corporatized medicine.

But back to the point being pushed earlier.... NP independence is not something that will be rolled back. Some folks in Texas are making a push with some legislation on reading x rays or something like that. Apart from the fact that Texas isn’t an independent state anyway, the anticompetitive purposes behind that kind of contraction in practice rights will be destroyed in courts. The evidence will be the fact that Nps practice independently in so many more places without compelling evidence to the contrary. That’s what drives this forward when there are legislative pushes by the ANA for NP practice expansion.... the utter lack of compelling evidence that there is any kind of problem. They see the physicians come to testify with anecdotal fears, and then they look at the budget and the access issues, and the fact that insurance companies (who aren’t known for throwing away money) are onboard with reimbursement, and they decide to eliminate supervision. Texas will be the last, but California will be the next state where the barriers fall (probably in the next 3 years). When California goes independent, it’s all over for antiquated supervision across the land. This conversation about going back in time is purely academic. Turning back the clock is not on the table anywhere.

What stares legislators in the face is the fact that the next state over, NPs are independent, and outcomes haven’t changed for the worse. There is an army of RNs, LPNs, CNAs, administrators, and as many NPs being churned out per year as physicians.... all of those people vote. Then you add in interest groups who want to see more access to medical care. They feel like physicians are rich fat cats who want to protect their corner of the market so they can buy a new boat and live larger. Nobody has the appetite to make them the gatekeepers for the market anymore. They aren’t even their own gatekeepers. Over 50 percent of physicians are now in a practice arrangement as an employee rather than as a practice owner. Now physicians are just one more group of workers among many. That’s all a perception that I don’t necessarily believe, but that’s what physicians are up against. It’s not the docs in the community clinics that are the face of this, it’s the ones who drive up in the Range Rover and take the nice vacations, and live in he nice part of town.

Case in point on physician clout.... a few years ago my facility switched to electronic medical records. Most of the physicians balked, threatened to leave, demanded accommodations like the ability to give most of their orders as verbals to the nurses, or demanded staff to input their written orders. They said it would impact their ability to be efficient. Alluded to better deals they could get elsewhere from other facilities who would accommodate them (that didn’t end up panning out because the other places ended up mandating it too). My facility told them all “I guess you can explore your other options because we are doing it this way, and we aren’t accommodating you. Use our system by this date or we have to replace you.” A couple retired. A few left to work elsewhere and ended up with a new EMR anyway. Some tried to play games and stick around while throwing sand in the gears (only to be told a new date to comply by, and offered one on one remediation). All of them made the transition. Nurses were told not to take verbals from the worst offenders, and we complied. One abusive physician was fired after nurses went to Human Resources to report the ongoing friction. At this point, physicians probably have better things to do than worry about NPs. It will be all they can do to keep what they have going on with other fronts.

 

[pamac]

A lot of the misperception between physicians who feel threatened and NPs comes down to projection. The critics imagine that independent NPs practice like cowboys with complete abandon. It’s not like that. NPs are responsible for the work they do, and the mistakes that are made. The blowback is harsh, and nobody is there to offer a soft landing if you blow it. The board of nursing isn’t letting us play fast and loose with the rules and keep our licenses, and the board of pharmacy isn’t letting us prescribe if we mess around with them. On the contrary, I’ve seen physicians given very generous sanctions (or lack thereof) for egregious behavior. Independence actually seems to promote positive ownership of our decisions. When you are working without a net, you are extra careful. You are even more careful when the landscape below you is beset with lions that will eat you.

 

[deleted171991]

(I am a critical care anesthesiologist.)

Associate providers can practice (more or less) independently in pattern-based (aka "monkey see monkey do") settings. Hence the push for protocols everywhere. GOOD critical care is NOT protocol-based, it's VERY dependent on the individual patient (and if one doesn't know what I mean, one has a lot to learn). So APP independence in ICU setting is playing with fire. While a good APP can be the equivalent of a bad/average physician intensivist, especially in simpler cases (anybody can follow a recipe book, even if it's called textbook or Uptodate), s/he can't hold a candle to a good one, for the simple reason that s/he lacks the basic science fundamentals necessary not to think in patterns, but in (patho)physiologic probabilities. For example, I personally would never want to be treated by an intensivist who just follows sepsis protocols, regardless of degree.

I trained in a fellowship program where a number of the patients were covered by APPs. They were better than most residents (anybody who does just one thing for years had better be), but they occasionally exhibited less than optimal judgment, resulting from knee-jerk behavior. The sicker and more complicated the patient, the more it showed. They were excellent at dotting the i's and crossing the t's, and at applying protocols. And, obviously, they were not independent, given the acuity.

IMO, any APP who thinks s/he's equivalent to most doctors is dangerous, in the ICU or elsewhere (unless we're talking about truly monkey see monkey do stuff, such as a bedside procedure). One should know what one doesn't know (physicians, too). The main reason we are not seeing worse outcomes with independent APP practice is because we still don't know how to measure them, and because physicians are still around to fix major mistakes. I would be curious to see the outcomes of a 100% non-physician-based hospital (there is a reason no bean counter has the balls to play that game). Administrators are betting that somebody with 20% of the knowledge will be able to treat 80% of the patients (and that's probably true). The problem is that we don't really know a priori which 80% should qualify, and that is the big bet that hurts patients for sure in independent practice (we just have to learn to measure it properly).

Sorry for the off-topic, but certain things can't go unanswered. I am not looking for an argument (I am a guest here), just pointing out stuff.

 

[deleted171991]

A lot of the misperception between physicians who feel threatened and NPs comes down to projection. The critics imagine that independent NPs practice like cowboys with complete abandon. It’s not like that. NPs are responsible for the work they do, and the mistakes that are made. The blowback is harsh, and nobody is there to offer a soft landing if you blow it. The board of nursing isn’t letting us play fast and loose with the rules and keep our licenses, and the board of pharmacy isn’t letting us prescribe if we mess around with them. On the contrary, I’ve seen physicians given very generous sanctions (or lack thereof) for egregious behavior. Independence actually seems to promote positive ownership of our decisions. When you are working without a net, you are extra careful. You are even more careful when the landscape below you is beset with lions that will eat you.

What you think is egregious may have been very well indicated. For example, one can run a pressor and a diuretic infusion at the same time, if that's what the patient requires, although a lot of bureaucrats, with weak clinical knowledge, would qualify it as bad medicine. Or transfuse a patient with a Hgb of 9, after a big bloody surgery, if s/he's persistently hypotensive despite being clearly normovolemic. Or use unusual drugs, or doses. And there are tons of examples like this, the kind that prompt confused questions from all kinds of healthcare workers, who get upset when one doesn't have the time and inclination to condense many years of under/graduate medical studies into an understandable (to them) explanation.

Good medicine is mostly NOT team care (just team advice), the same way a US president doesn't really govern by committee. The buck has to stop with somebody, and that person matters tremendously (though not exclusively).

 

[pamac]

The egregious things I thought of actually weren’t in the clinical realm, but rather behavior... ie misconduct with patients.

I’m a respecter of physicians and the skill set. What i take issue with is a dependent organizational structure that isn't changing with the times. It seems like physicians are worried if they don’t come as a package deal with direct authority over APPs, that they will lose out. My thought is that with their training and quality, they will be the top of the food chain under all scenarios. Quality speaks for itself. I simply don’t feel that folks are going to push physicians out of anywhere, unless it’s administrations that would do it anyway.

 

[deleted171991]

@pamac, I don't really have an issue with experienced APPs practicing independently, especially on well-chosen patients and in "safer" chronic specialties (although I am way too picky to accept their care for my family - that also applies to many physicians). I understand that there is a physician shortage in certain parts of the country, and that everywhere hospitals are way too greedy, so they try to cut even that 7-8% which is the real cost of the physician in the hospital bill. I also know that the ship has sailed, and pushing against this agenda will make me unemployed pretty fast, so I try to find an ethical and practical way to live with my employer's agenda.

I do have an issue with young inexperienced APPs practicing unsupervised (some nursing schools are downright diploma mills when compared to any American medical school, no offense - online/"hybrid" healthcare degree, seriously?, that should be an oxymoron). I also prefer not to practice alongside independent APPs in a "collaborative" model. If they want to be "independent", I won't be their firefighter who fixes their mistakes and near misses, or who takes care only of the sicker and more stressful patients (aka pick and choose).

Quality should speak for itself, indeed. Unfortunately, the average person has an IQ of about 100 (which is pretty unimpressive) or worse, and that's about 50% of the population. One third of the population has an IQ of under 84-85, which is so low that even the US military would refuse them. These people are one of the reasons why American malpractice laws are paternalistic (e.g. one cannot sign away one's right to sue for malpractice, the physician is responsible for offering only treatments within the standard of care, regardless of the patient's wishes etc.). They need to be protected from themselves, unless we let natural selection follow its course (which I personally don't disagree with, but the politically correct do - for example, we prevent alcohol withdrawal in chronic alcoholics with sedatives, instead of IV ethanol or PO alcoholic drinks).

Also, because the average person doesn't really have the analytic equipment to notice the difference in outcomes, many physicians are rightly concerned that they will lose patients, even if their care/knowledge is obviously superior. Most people are not intelligent enough to make purely rational decisions; they are mostly emotional beings, hence the postmodern concept of emotional "intelligence" (so that dumb people, who can't think logically - which is what the IQ test measures - won't feel bad). They are the ones the "heart of a nurse" APRN ads are aimed at. These people will believe a lot of stuff they are told, even if outright lies; for example, that physicians and APPs have equivalent education, just through different pathways. The whole concept of DNP was invented to try to fool these fools: it's still a doctor, just a "nurse doctor" (ND - doesn't it sound/look like MD?). Even highly intelligent people can be dumb when about healthcare decisions (e.g. Steve Jobs). Another proof that there is a serious public health issue about independent practice.

And let's not mention that most MDs (not to speak about APPs) have no friggin' idea how to properly interpret a research paper, hence the 95+% of papers that are worthless and get contradicted sooner or later (please read Dr. John Ioannidis for exact numbers and concepts). But hey, all of them get to treat patients and establish the standard of care. Advanced mathematics should be a requirement for practicing medicine in any of its forms (says the guy with a minor in Math). But I digress...

We also live in a country which has a long history of blue-collar anti-intellectual streak (some communist proletariats would be proud) - just look at our presidents (few were intellectual powerhouses) - and that was before the age of Internet and social media, when everybody is an "expert". Hence antivaxxers, hence people not following medical advice (I had a HbA1c of 10 patient tell me that he switched from a physician's antidiabetic presciption to what his blue-collar friend advised, and he was praising the friend). In this era, the true experts disappear in the sea of quacks and Dunning-Kruger examples (the latter including many cocky APPs).

Unfortunately, most professional APRN organizations are downright disgusting in how low they have sunk pushing their independent practice agenda (which only exists because Big Healthcare has a serious financial interest in it), and many physicians see APPs as the extensions of these organizations (hence the lack of respect by default). For example, I have found that the most reasonable non-militant well-prepared experienced CRNAs I work with all hate the AANA, almost without exception (and the other way round).

 

[pamac]

There are qualms I have with NPs despite my degree. Many an nucking futts, and I know several that are a pain in the butt. For instance... As an RN, I’ve never really been treated poorly by a physician. Maybe I’m an extreme outlier, or maybe I came across to them as competent, but my interactions have left me impressed at their level of self control. I’ve heard horror stories, even from my immediate peers, but I’m not sheltered nor naive. I’ve met a lot of physicians and interacted with them. Conversely, the Nps I’ve worked with have been nightmares except for a handful. My sample size is around 10 that’s I've actually worked with as an RN, and most of those have been inpatient and ICU based Nps. Poor performers, quick to feel entitled and cop and attitude with the nurses. Watched one that criticized me to my supervisor for something I did right (she “just didn’t feel like I knew what I was doing”) end up destroying a patient’s kidneys months later merely by her own mistake. One walked by a patient and said “you should put some ears on that patient, she sounds like she has wet lungs”. That was pretty impressive considering that the NP was 15 feet away and I had already listened to the patient and they were just fine. I never precepted with fools like that in training because I always picked the top notch NPs. But I know what the landscape is like. I’m glad that the nut jobs cleared the way for me to have a pathway to be independent, but I await the great cleansing when folks like me do well because of word of mouth while the fools fall by the wayside. I think the powers that be can tell the good from the bad, because physicians have always been fine with me and spoke well of me in my training (I had more physician/psychiatrist preceptors than NPs). My unsolicited job offers have all come from physicians. Many of my peers will have a tough time.

 

[Fiveoboy11]

(I am a critical care anesthesiologist.)

Associate providers can practice (more or less) independently in pattern-based (aka "monkey see monkey do") settings. Hence the push for protocols everywhere. GOOD critical care is NOT protocol-based, it's VERY dependent on the individual patient (and if one doesn't know what I mean, one has a lot to learn). So APP independence in ICU setting is playing with fire. While a good APP can be the equivalent of a bad/average physician intensivist, especially in simpler cases (anybody can follow a recipe book, even if it's called textbook or Uptodate), s/he can't hold a candle to a good one, for the simple reason that s/he lacks the basic science fundamentals necessary not to think in patterns, but in (patho)physiologic probabilities. For example, I personally would never want to be treated by an intensivist who just follows sepsis protocols, regardless of degree.

I trained in a fellowship program where a number of the patients were covered by APPs. They were better than most residents (anybody who does just one thing for years had better be), but they occasionally exhibited less than optimal judgment, resulting from knee-jerk behavior. The sicker and more complicated the patient, the more it showed. They were excellent at dotting the i's and crossing the t's, and at applying protocols. And, obviously, they were not independent, given the acuity.

IMO, any APP who thinks s/he's equivalent to most doctors is dangerous, in the ICU or elsewhere (unless we're talking about truly monkey see monkey do stuff, such as a bedside procedure). One should know what one doesn't know (physicians, too). The main reason we are not seeing worse outcomes with independent APP practice is because we still don't know how to measure them, and because physicians are still around to fix major mistakes. I would be curious to see the outcomes of a 100% non-physician-based hospital (there is a reason no bean counter has the balls to play that game). Administrators are betting that somebody with 20% of the knowledge will be able to treat 80% of the patients (and that's probably true). The problem is that we don't really know a priori which 80% should qualify, and that is the big bet that hurts patients for sure in independent practice (we just have to learn to measure it properly).

Sorry for the off-topic, but certain things can't go unanswered. I am not looking for an argument (I am a guest here), just pointing out stuff.

You're telling me that physician conduct is individual patient based with regard to physical therapy? No, it's by and large knee jerk, Get-R-done B.S. It's quite the task just to deal with that as a physical therapist in the acute hospital setting. There's immense amounts of cumulative waste and abuse with net effect of harm to other patients as we're not in infinite supply or with infinite time. You see a patient "walkin' in the hallway" and therefore they're "good to go" ay doc? You base rehab decisions on little to nothing constantly. You don't know how to read or interpret rehab notes. You have no fundamentals with regard to physical therapy in any way. You have zero accountability for your absolute incompetence. You've seen your monkey colleagues do it thru your training, now you're doing it. So stop selling crazy with your nonsense because it's B.S.

 

[deleted171991]

You're telling me that physician conduct is individual patient based with regard to physical therapy? No, it's by and large knee jerk, Get-R-done B.S. It's quite the task just to deal with that as a physical therapist in the acute hospital setting. There's immense amounts of cumulative waste and abuse with net effect of harm to other patients as we're not in infinite supply or with infinite time. You see a patient "walkin' in the hallway" and therefore they're "good to go" ay doc? You base rehab decisions on little to nothing constantly. You don't know how to read or interpret rehab notes. You have no fundamentals with regard to physical therapy in any way. You have zero accountability for your absolute incompetence. You've seen your monkey colleagues do it thru your training, now you're doing it. So stop selling crazy with your nonsense because it's B.S.

I am an intensivist. I am not a physical therapist (or a PMR specialist). I don't tell nurses how to bathe the patient either. Sorry, that's not intensive care. I don't know what you're smoking, but you definitely have a problem. You are like nurses who hate being called nurse. If you don't like your job, maybe you should look for something that makes you feel happier or more important.

In the meanwhile, learn what my job, as an ICU physician, actually is. It's not rehab. Here, this is my board exam content outline: http://www.theaba.org/PDFs/Critical-Care-Medicine/ContentOutline_CCM . Do you see any physical therapy here? I don't tell allied healthcare workers how to do their jobs, which they are supposed to know better than me. One cannot know everything, hence one chooses to learn what actually makes a BIG difference. PT is not one of them. By the way, I will read the swallow evals and chat with the speech therapist, the same way I read nursing notes and most of the stuff that shows up in the chart, especially if I was the one who asked for a consult. I would also happily chat with the physical therapist and learn how I could help him/her, if that helps the patient. Interestingly this is the first PT temper tantrum or complaint I have heard in a decade.

And, by the way, anesthesiologist-intensivists don't send anybody to rehab. That's the primary surgeon's job. Before you insult people, at least get informed. Or, as some would say, educated.

 

[762513]

I am an intensivist. I am not a physical therapist (or a PMR specialist). I don't tell nurses how to bathe the patient either. Sorry, that's not intensive care. I don't know what you're smoking, but you definitely have a problem. You are like nurses who hate being called nurse. If you don't like your job, maybe you should look for something that makes you feel happier or more important.

In the meanwhile, learn what my job, as an ICU physician, actually is. It's not rehab. Here, this is my board exam content outline: http://www.theaba.org/PDFs/Critical-Care-Medicine/ContentOutline_CCM . Do you see any physical therapy here? I don't tell allied healthcare workers how to do their jobs, which they are supposed to know better than me. One cannot know everything, hence one chooses to learn what actually makes a BIG difference. PT is not one of them. Interestingly, I will read the swallow evals and chat with the speech therapist, the same way I read nursing notes and most of the stuff that shows up in the chart, especially if I was the one who asked for a consult. I would also happily chat with the physical therapist and learn how I could help him/her, if that helps the patient. Interestingly this is the first PT temper tantrum or complaint I have heard in a decade.

And, by the way, anesthesiologist-intensivists don't send anybody to rehab. That's the primary surgeon's job. Before you insult people, at least get informed. Or, as some would say, educated.

I worked in an ICU for many years before becoming an NP. It was the trust I built with the intensivists that got me my first NP job. You are correct about the problems with NP education, and for that reason, the NP's that are hired need to be chosen very carefully. The most important thing for an NP to know, whether they are just out of school or 10 years into their career, is if a patient is in trouble or not. That's somethings that's learned from experience, and is actually more wisdom than knowledge. That's one area where NP's can outshine PA's. After many, many years in the ICU, I would call the attending directly and all I would have to say is "this person is in trouble" and they would come immediately, usually with ETT in hand. New NP's have a ton to learn, and it will take years, but if you hire the right one they will succeed. The biggest argument I hear against NP's is lack of experience and diploma mills and there's an easy solution; don't hire those people.

 

[PikminOC]

Nurses take chemistry as pre read for nursing school. Although an intro course is all that is required at least they have a foundation. I would not go so far as to say they don’t know what acids and bases are.

The nursing classes are watered down and they are competing with other midlevels.