APP (NP/PA) staffing trends in ICU

[blue.jay]

Looking to hear opinions from practicing medical intensivist about their experience with APP use in ICU. Due to rapid increase in NP and PA schools they are working in almost every specialty. During residency I was annoyed working with some ICU RNs who were snobby and arrogant. How is it to work along with APPs; with trends in tele-ICU and APP encroachment in units will there be good jobs 5-10 yr down the line for someone considering CCM or Pulm-CCM fellowship? I usually prefer to work alone or with residents and medical students; I haven't enjoyed collaborating with APP in my job. Is it possible to get Pulm-crit job in physician only practice model 5-10 years from now?

The article below says, though APPs won't replace intensivist but supports their extensive use in ICU setting

Nurse Practitioners and Physician Assistants in Acute and... : Critical Care Medicine

EDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. Study Selection: Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. Data Extraction...

journals.lww.com

---

Members don't see this ad.

 

[CCM-MD]

The lack of a physician author on that paper speaks volumes.

In my opinion, CCM hasn’t seen as much mid level encroachment as anesthesia, EM and primary care YET. Which only means that it’s coming. Hard to predict the future but things are only going to get worse. We are also seeing more CMGs in critical care, like Sound. Those companies love midlevels.

All that being said, I don’t know what else I would do. I can’t see myself doing another IM sub specialty. If I could go all the way back I would probably work my ass off to get into a surgical sub or radiology maybe.

 

[chocomorsel]

The lack of a physician author on that paper speaks volumes.

In my opinion, CCM hasn’t seen as much mid level encroachment as anesthesia, EM and primary care YET. Which only means that it’s coming. Hard to predict the future but things are only going to get worse. We are also seeing more CMGs in critical care, like Sound. Those companies love midlevels.

All that being said, I don’t know what else I would do. I can’t see myself doing another IM sub specialty. If I could go all the way back I would probably work my ass off to get into a surgical sub or radiology maybe.

Agreed. It’s coming. I am from an anesthesia background and my fellowship had a lot of mid levels. The CICUs were staffed by us, supposedly but they had the midlevels carrying out their bidding while they were operating in the OR. And some those midlevels had horrendous attitudes.
But the ones who were employed by the anesthesia department were cool except for one crazy know it all one. She deserved the abuse she got from one of our attendings daily.

 

[blue.jay]

Agreed. It’s coming. I am from an anesthesia background and my fellowship had a lot of mid levels. The CICUs were staffed by us, supposedly but they had the midlevels carrying out their bidding while they were operating in the OR. And some those midlevels had horrendous attitudes.
But the ones who were employed by the anesthesia department were cool except for one crazy know it all one. She deserved the abuse she got from one of our attendings daily.

Makes me wonder what their attitude would be after 10-20 years in practice as NP, especially to a new attending right out of fellowship.
It's already stressful to deal with tantrums of a ICU nurse, having an arrogant NP in the team would make me go insane.

 

[chocomorsel]

Makes me wonder what their attitude would be after 10-20 years in practice as NP, especially to a new attending right out of fellowship.
It's already stressful to deal with tantrums of a ICU nurse, having an arrogant NP in the team would make me go insane.

We had a screaming match one day. The attending came and just closed the door. It was funny.
She was the exception though. The rest were mostly OK except maybe one other one who should never had been hired because of her bad attitude as an RN but I guess they needed bodies.

 

[CCM-MD]

I encountered a few annoying NPs in fellowship too but most midlevels were pleasant note/order writers. All my jobs has an attending have had midlevels. Luckily haven’t had issues, most have helped tremendously with the documentation and EMR burden.

This is how it starts though, once they proliferate they will likely cause major problems.

 

[chessknt]

I've never encountered a ccm mid-level who worked on medical ICU patients. The surgical (primarily cardiac surgery) icus had midlevels and they were great at running algorithm care in routine post-op patients and helped facilitate good care with lots of resident turnover. The medical side in 6 different hospitals during my training had 0 midlevels. I know a large part of that was due to lack of department funding because Micus didn't get surgeon money but I never saw a np student or rotator either so there must have been no academic interest either.

I can't imagine many midlevels want the grueling hours of ccm to be paid less than a crna while dealing with medically sick patients that don't follow a series of easily run algorithms, often have dismal prognoses and/or crazy families that want the full package on clearly declining elderly folks, and usually have poor outcomea. I'm not worried about encroachment at all to be honest.

 

[SurfingDoctor]

I’ve encountered that model since fellowship over a decade ago and thought it was fine. Of course, there is the occasional unpleasant one, but most are easy to work with and make my work much faster as opposed to residents.

 

[chocomorsel]

I've never encountered a ccm mid-level who worked on medical ICU patients. The surgical (primarily cardiac surgery) icus had midlevels and they were great at running algorithm care in routine post-op patients and helped facilitate good care with lots of resident turnover. The medical side in 6 different hospitals during my training had 0 midlevels. I know a large part of that was due to lack of department funding because Micus didn't get surgeon money but I never saw a np student or rotator either so there must have been no academic interest either.

I can't imagine many midlevels want the grueling hours of ccm to be paid less than a crna while dealing with medically sick patients that don't follow a series of easily run algorithms, often have dismal prognoses and/or crazy families that want the full package on clearly declining elderly folks, and usually have poor outcomea. I'm not worried about encroachment at all to be honest.

It’s not as much about the money for some of these people as it is about the power. The power they feel when they claim equivalency working in the ICUs. And then lobby for more power.
Seen them in MICU in my training.
Unfortunately, we are doing this to ourselves.

 

[blue.jay]

How much of this HRSA report is true for critical care? Will there be enough jobs in the next 5-10 years? If I'm not happy with the job (due to workplace dynamics and politics) will it easier to find another job? The oversupply of nurse practitioners is very concerning

 

[chessknt]

View attachment 309490

How much of this HRSA report is true for critical care? Will there be enough jobs in the next 5-10 years? If I'm not happy with the job (due to workplace dynamics and politics) will it easier to find another job? The oversupply of nurse practitioners is very concerning

Job market is better than fine in my experience even though according to this we should be ok our way to totally replaced by nps by now. seems like fake news.

 

[grt398]

My IM residency had a separate NP/PA team in the MICU that was staffed with a separate attending from the resident team and had two mid-levels during the day, and one at night. They normally carried 2-4 patients per person, so it's definitely out there in academic MICU's. Our resident team was usually 12-16 pts for comparison.

 

[ShockIndex]

We had a screaming match one day. The attending came and just closed the door. It was funny.
She was the exception though. The rest were mostly OK except maybe one other one who should never had been hired because of her bad attitude as an RN but I guess they needed bodies.

From my high school years - be nice...



It’s how I live my life.

 

[CCM-MD]

I've never encountered a ccm mid-level who worked on medical ICU patients. The surgical (primarily cardiac surgery) icus had midlevels and they were great at running algorithm care in routine post-op patients and helped facilitate good care with lots of resident turnover. The medical side in 6 different hospitals during my training had 0 midlevels. I know a large part of that was due to lack of department funding because Micus didn't get surgeon money but I never saw a np student or rotator either so there must have been no academic interest either.

I can't imagine many midlevels want the grueling hours of ccm to be paid less than a crna while dealing with medically sick patients that don't follow a series of easily run algorithms, often have dismal prognoses and/or crazy families that want the full package on clearly declining elderly folks, and usually have poor outcomea. I'm not worried about encroachment at all to be honest.

What? They are everywhere. I had them in fellowship (IM-CCM) at all 3 hospitals we rotated through. And all of the community jobs I have had as an attending.

 

[chessknt]

I've been centered at VA and academic hospitals in the midwest (4 diff health systems and cities in 3 states)--are you all on the coast or did I just have an unusual avoidance of micu midlevels?

 

[CCM-MD]

I've been centered at VA and academic hospitals in the midwestb(4 diff health systems and cities in 3 states)--are you all on the coast or did I just have an unusual avoidance of micu midlevels?

Residency in NE. Fellowship in the midwest. And I have worked in the midwest, south, and NE as an attending at various community hospitals including locums. Literally every single gig I have had, has had a PA or an NP in the unit with me.

 

[deleted547339]

I wouldn’t let midlevels dissuade you from a career in CCM, especially PCCM. The sickest patients need a doctor. Period.

 

[blue.jay]

I

I wouldn’t let midlevels dissuade you from a career in CCM, especially PCCM. The sickest patients need a doctor. Period.

I don't believe CCM will be replaced by midlevels completely.
I agree that we need highly trained Physicians in the unit, but certain things are not under our control. What if the hospital system decides to hire 1 MD and 2 NPs (instead of having more MD support) to staff a busy ICU and expect us to supervise midlevels. I want to enjoy my job and look forward to work for the next 30-40 years, I'm worried these workplace changes will lead to burnout.

 

[deleted547339]

I


I don't believe CCM will be replaced by midlevels completely.
I agree that we need highly trained Physicians in the unit, but certain things are not under our control. What if the hospital system decides to hire 1 MD and 2 NPs (instead of having more MD support) to staff a busy ICU and expect us to supervise midlevels. I want to enjoy my job and look forward to work for the next 30-40 years, I'm worried these workplace changes will lead to burnout.

It sounds like you’ve made up your mind and not here for advice/others opinion, which is fine. But if you want the opinion of people in the field, this is my opinion.

 

[blue.jay]

It sounds like you’ve made up your mind and not here for advice/others opinion, which is fine. But if you want the opinion of people in the field, this is my opinion.

Thank You

 

[CCM-MD]

I


I don't believe CCM will be replaced by midlevels completely.
I agree that we need highly trained Physicians in the unit, but certain things are not under our control. What if the hospital system decides to hire 1 MD and 2 NPs (instead of having more MD support) to staff a busy ICU and expect us to supervise midlevels. I want to enjoy my job and look forward to work for the next 30-40 years, I'm worried these workplace changes will lead to burnout.

I love what I do right now - even while working with midlevels. But no one can predict the future. One thing is for sure, there will be more and more midlevels and what you mentioned could be a possible scenario. I agree with @TimesNewRoman that the sickest patients need a doctor, but it doesn't matter what he or I think. It matters what the hospital admin thinks, and they might think the sickest patients need 1 MD and 5 NPs instead of 5 MDs.

 

[blue.jay]

I love what I do right now - even while working with midlevels. But no one can predict the future. One thing is for sure, there will be more and more midlevels and what you mentioned could be a possible scenario. I agree with @TimesNewRoman that the sickest patients need a doctor, but it doesn't matter what he or I think. It matters what the hospital admin thinks, and they might think the sickest patients need 1 MD and 5 NPs instead of 5 MDs.

Thanks for your opinion @CCM-MD

 

[ShockIndex]

I love what I do right now - even while working with midlevels. But no one can predict the future. One thing is for sure, there will be more and more midlevels and what you mentioned could be a possible scenario. I agree with @TimesNewRoman that the sickest patients need a doctor, but it doesn't matter what he or I think. It matters what the hospital admin thinks, and they might think the sickest patients need 1 MD and 5 NPs instead of 5 MDs.

I


I don't believe CCM will be replaced by midlevels completely.
I agree that we need highly trained Physicians in the unit, but certain things are not under our control. What if the hospital system decides to hire 1 MD and 2 NPs (instead of having more MD support) to staff a busy ICU and expect us to supervise midlevels. I want to enjoy my job and look forward to work for the next 30-40 years, I'm worried these workplace changes will lead to burnout.

This is why we need more acute care physicians in senior hospital leadership who don’t turn into Benedict Arnolds in the first week of having a 7th floor office.

 

[ShockIndex]

I post an iconic videoclip from a cinematographic masterpiece and it doesn’t get one like...not one. You people either just got weaned from the teet, or you’re some of the most uncultured SOBs I’ve ever met.

 

[deleted171991]

I post an iconic videoclip from a cinematographic masterpiece and it doesn’t get one like...not one. You people either just got weaned from the teet, or you’re some of the most uncultured SOBs I’ve ever met.

I Liked it before I read this post.

 

[jthedestroyr]

I post an iconic videoclip from a cinematographic masterpiece and it doesn’t get one like...not one. You people either just got weaned from the teet, or you’re some of the most uncultured SOBs I’ve ever met.

I totally just watched roadhouse yesterday!

 

[ShockIndex]

I totally just watched roadhouse yesterday!

....and you are a better man now because of it.

In all seriousness, Patrick Swayze was one of the “Good Guys” of Hollywood. He didn’t screw around on his wife and he did a ton of charity work. He, along with Christopher Reeve had profound impacts on my childhood: Superman, The Outsiders, Red Dawn, and Roadhouse where the schizzle.

Sometimes, I like to reenact those years by helping to direct traffic with my Superman Underoose and a red cape, or running around my neighborhood with an AK fighting invading Russians.

 

[thorwayCC]

I think we are heading toward the same situation as anesthesiology and emergency medicine. I stumbled upon this and https://www.researchgate.net/public...ssistant_Staffing_and_Critical_Care_Mortality.
poor studies but flashy enough for admins.

 

[PTPoeny]

Everywhere I have been the APPs in the ICU are basically extra residents. I don't see how they could affect attending positions. It takes just as much time and effort to supervise an APP as a resident.

 

[chocomorsel]

I think we are heading toward the same situation as anesthesiology and emergency medicine. I stumbled upon this and https://www.researchgate.net/public...ssistant_Staffing_and_Critical_Care_Mortality.
poor studies but flashy enough for admins.

Well, this is interesting.

 

[Modanq]

Medicine is in a race to the bottom. Physicians need to come together. Only time will tell if we can separate from the garbage that is practiced out there. Beware they will come for your jobs.

Every field is at peril. I see daily notes from NPs in nephrology, cardiology, ID services who were "consulted" for pts in the ICU. The notes are written by nps and the pts seen by an army of nps and cosigned by an attending with limited input. Soon you won't need an attending MD physician signature. EPIC or other EMRs are now even built saying the NP is the attending.

Hospital admin love this. More tests, more prescribing, more consults. See the example of CT lung screening. Prior authorization from a radiologist was needed for screening lung CT orders. Work around hire a radiology NP to order CT lungs. Oh wait why stop there let's have the NP read CXRs and screening lung CTs. Its open season. See recent paper about NPs reading in radiology and California's New ruling.

ICU physicians will not out pace the glutton of NP factory mills. There are forces in Healthcare beyond MD control. This year alone 12000 students applied to 90 spots at Stanford, 10000 applied to 120 spots at BU medical school. You better believe that 1000s of these reject students go on to become NPs, CRNAs, PAs. In a nice reference from SDN Everyone wants to practice medicine but no one wants to lift some heavy *ss books.

 

[bronx43]

ICU physicians will not out pace the glutton of NP factory mills. There are forces in Healthcare beyond MD control. This year alone 12000 students applied to 90 spots at Stanford, 10000 applied to 120 spots at BU medical school. You better believe that 1000s of these reject students go on to become NPs, CRNAs, PAs. In a nice reference from SDN Everyone wants to practice medicine but no one wants to lift some heavy *ss books.

Perhaps it sounds like they want to lift some heavy *ss books, but the medical industrial complex won't let them in the form of MD/DOs.

 

[turkeyjerky]

Perhaps it sounds like they want to lift some heavy *ss books, but the medical industrial complex won't let them in the form of MD/DOs.

Let's be honest here. A lot of them aren't strong enough to lift those books.

 

[bronx43]

Let's be honest here. A lot of them aren't strong enough to lift those books.

I think someone of slightly above average strength can lift those books. It's simply that there are quite a few books. But let's not act like they're barrels of rocket fuel.

 

[thorwayCC]

Everywhere I have been the APPs in the ICU are basically extra residents. I don't see how they could affect attending positions. It takes just as much time and effort to supervise an APP as a resident.

I ve seen them work solo with attending at home on nights..

 

[PTPoeny]

I ve seen them work solo with attending at home on nights..

Yes, just like a resident.

 

[chocomorsel]

I ve seen them work solo with attending at home on nights..

This is my current gig. I get called often enough. Guess the facility can’t afford a full time doc. Lots of places can’t supposedly. But are apparently affording ICU nurses to the tune of >$100 an hour these days.

 

[MLNS]

Yes, just like a resident.

You’re probably one of the dingus (read: sellout) attendings who train midlevels. News flash, what do you thinks gonna happen once they gain independence in every state? There goes your attending position you so intelligently (read: sarcasm) think they won’t affect

 

[chocomorsel]

You’re probably one of the dingus (read: sellout) attendings who train midlevels. News flash, what do you thinks gonna happen once they gain independence in every state? There goes your attending position you so intelligently (read: sarcasm) think they won’t affect

Maybe he or she is a sellout.
But what is your alternative? Just have the doc come in every night for admissions and emergencies?
I think it honestly sucks both ways but the old way had been for the doc to rotate call for 24 hours w his partners and probably come in at night a few times.
The new way now is that hospitals want 24 hour in house coverage but don’t want to have to pay physicians for it. So what’s the best alternative?
Maybe go back to the old way?

 

[Modanq]

Venture over to the yale ER thread regarding a joint PA and MD residency program. Its a death spell. Nail in the coffin.

 

[psychbender]

The best alternative is for hospitals to pony up the money for 24/7 in-house physician coverage.

 

[thorwayCC]

Maybe he or she is a sellout.
But what is your alternative? Just have the doc come in every night for admissions and emergencies?
I think it honestly sucks both ways but the old way had been for the doc to rotate call for 24 hours w his partners and probably come in at night a few times.
The new way now is that hospitals want 24 hour in house coverage but don’t want to have to pay physicians for it. So what’s the best alternative?
Maybe go back to the old way?

old way, hire a night doc, train more fellows and residents..We cant be short changing our patients by leaving them for hours without actual in house coverage. Pathophysiology is vast in even the less acute ICU and stuff go south very quickly.. One of the local community hospitals learned it the hard way, after a significant error on nights, they fired the two NPs that work on nights and hired one intensivist in the unit instead.

 

[deleted126335]

Maybe he or she is a sellout.
But what is your alternative? Just have the doc come in every night for admissions and emergencies?
I think it honestly sucks both ways but the old way had been for the doc to rotate call for 24 hours w his partners and probably come in at night a few times.
The new way now is that hospitals want 24 hour in house coverage but don’t want to have to pay physicians for it. So what’s the best alternative?
Maybe go back to the old way?

Please think of this post when you next post in the anesthesia forum criticizing the previous generation for being "sell outs" for increased utilization of CRNAs when faced with in every increasing demand for service.

 

[chocomorsel]

Please think of this post when you next post in the anesthesia forum criticizing the previous generation for being "sell outs" for increased utilization of CRNAs when faced with in every increasing demand for service.

I am totally trying to figure out what a better plan is. I don't think the best plan is to have a midlevel at night, but to have a doc at night. It's just that doing 24 hours, and then another 12 hours the next day in house till your next call day is unsustainable IMO. Some hospitals are paying for docs at night, but many aren't.
I am a locums. Just trying to get a good idea of what is the best option.

Those docs I accuse of selling out are the ones who swear up and down that the ACT model is proven to be just as good if not better than the physician only model. As they make money off their CRNAs. And talk about how much they hate to "stool sit" like it's beneath them. I understand many are stuck and have no option but the ones who defend the ACT model as the best option, come on. I don't think the midlevel at night is the best option either, but it may be better than an exhausted doc doing that all night and working a full on day the next day. Unless we are talking of having the post call day off.

I don't have the answers. Just saying the old way seems brutal, and the new way, not all hospitals can "afford."

Come on, the previous generations did a lot of selling us out.

 

[chocomorsel]

old way, hire a night doc, train more fellows and residents..We cant be short changing our patients by leaving them for hours without actual in house coverage. Pathophysiology is vast in even the less acute ICU and stuff go south very quickly.. One of the local community hospitals learned it the hard way, after a significant error on nights, they fired the two NPs that work on nights and hired one intensivist in the unit instead.

And that's exactly what I think as well. And how do you make these hospitals not just look at the bottom line though and try to find the cheapest alternative, the midlevel.
The old way of doctors being on call 24 hours and then working the next day is brutal and unsafe. Maybe better if there was post call day off. But Gosh I hate call.

 

[deleted126335]

I am totally trying to figure out what a better plan is. I don't think the best plan is to have a midlevel at night, but to have a doc at night. It's just that doing 24 hours, and then another 12 hours the next day in house till your next call day is unsustainable IMO. Some hospitals are paying for docs at night, but many aren't.
I am a locums. Just trying to get a good idea of what is the best option.

Those docs I accuse of selling out are the ones who swear up and down that the ACT model is proven to be just as good if not better than the physician only model. As they make money off their CRNAs. And talk about how much they hate to "stool sit" like it's beneath them. I understand many are stuck and have no option but the ones who defend the ACT model as the best option, come on. I don't think the midlevel at night is the best option either, but it may be better than an exhausted doc doing that all night and working a full on day the next day. Unless we are talking of having the post call day off.

I don't have the answers. Just saying the old way seems brutal, and the new way, not all hospitals can "afford."

Come on, the previous generations did a lot of selling us out.

Some of what you define as "selling out", I define as doing the math and making the same type of hard choices that critical care docs are facing in training and utilizing APPs.

 

[thorwayCC]

And that's exactly what I think as well. And how do you make these hospitals not just look at the bottom line though and try to find the cheapest alternative, the midlevel.
The old way of doctors being on call 24 hours and then working the next day is brutal and unsafe. Maybe better if there was post call day off. But Gosh I hate call.

Physicians have a say on who hospital hires! especially senior members of the team, admin can push NP on the team but still needs team approval. Create quality studies that actually compare intensivist knowledge vs NP & Quality studies comparing NP vs 24/7 actual intensivist coverage..Train fellows and residents well & give them preference to education and procedures over NPs.
Advocate with AMA and work with SCCM to change their rhetoric. Anesthesia and EM groups were asleep until now when its too late.

Also if you hire NPs, make sure roles are identified and limitations are in place..

 

[chocomorsel]

Some of what you define as "selling out", I define as doing the math and making the same type of hard choices that critical care docs are facing in training and utilizing APPs.

Alright. I give you that.
But what do you mean “doing the math?”

 

[chocomorsel]

Physicians have a say on who hospital hires! especially senior members of the team, admin can push NP on the team but still needs team approval. Create quality studies that actually compare intensivist knowledge vs NP & Quality studies comparing NP vs 24/7 actual intensivist coverage..Train fellows and residents well & give them preference to education and procedures over NPs.
Advocate with AMA and work with SCCM to change their rhetoric. Anesthesia and EM groups were asleep until now when its too late.

Also if you hire NPs, make sure roles are identified and limitations are in place..

Where are you in your training? I am not doing that to try and prove anything other than the fact that from what I hear and see admin does not give a crap about physicians and what they say unless they are money makers. As in people who bring patients to the hospitals for preferably procedures. I.E surgeons.
ER and Anesthesia are not the type of docs that bring money to the hospital. We are an expense to them.

 

[thorwayCC]

Where are you in your training? I am not doing that to try and prove anything other than the fact that from what I hear and see admin does not give a crap about physicians and what they say unless they are money makers. As in people who bring patients to the hospitals for preferably procedures. I.E surgeons.
ER and Anesthesia are not the type of docs that bring money to the hospital. We are an expense to them.

Attending.
Never seen my department chair being pushed to hire someone by admin without asking & approving.
Sure for anesthesia. ED and CCM are not dependent on surgeons money.