APP (NP/PA) staffing trends in ICU

[chocomorsel]

There is an updated one. This one pissed off a bunch of people off.

This is apparently the updated version. Again, it makes no sense. Why is an anesthesiologist different from a "non ICU physician?"

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[turkeyjerky]

This is apparently the updated version. Again, it makes no sense. Why is an anesthesiologist different from a "non ICU physician?"

My only thought would be that anesthesiologists would be solely performing vent management on a number of patients, allowing other physicians to focus on non-vent aspects of patient care. But I agree, that whole thing is stupid.

 

[FunnyDocMan1234]

Next decade is going to be these midlevels managing sick dying patients in the ICU.

So many training programs have started so they can saturate the job market. Looks like EM kind of situation is next for crit

I really don't think that's possible. In EM, the difference is that APPs can practice independently (in some places) or be supervised while doing the same work that an EM physician had been doing (e.g. being the frontline provider and putting in orders, etc) resulting in less demand for EM physicians.

In the ICU, no APP societies or even APPs are pushing to practice independently. Again, this is a situation such as major surgery in which the general public will not be ok with an APP being in charge with no physician supervision.

Intensivists generally aren't frontline providers who answer pages from nurses and place orders so nothing really will change for intensivist demand if more of the frontline providers are APPs as opposed to hospitalists.

 

[Matthew9Thirtyfive]

I really don't think that's possible. In EM, the difference is that APPs can practice independently (in some places) or be supervised while doing the same work that an EM physician had been doing (e.g. being the frontline provider and putting in orders, etc) resulting in less demand for EM physicians.

In the ICU, no APP societies or even APPs are pushing to practice independently. Again, this is a situation such as major surgery in which the general public will not be ok with an APP being in charge with no physician supervision.

Intensivists generally aren't frontline providers who answer pages from nurses and place orders so nothing really will change for intensivist demand if more of the frontline providers are APPs as opposed to hospitalists.

Aren’t they going to start having nurses do minor surgery in the UK?

 

[blue.jay]

I really don't think that's possible. In EM, the difference is that APPs can practice independently (in some places) or be supervised while doing the same work that an EM physician had been doing (e.g. being the frontline provider and putting in orders, etc) resulting in less demand for EM physicians.

In the ICU, no APP societies or even APPs are pushing to practice independently. Again, this is a situation such as major surgery in which the general public will not be ok with an APP being in charge with no physician supervision.

Intensivists generally aren't frontline providers who answer pages from nurses and place orders so nothing really will change for intensivist demand if more of the frontline providers are APPs as opposed to hospitalists.

Though many states have FPA, big name hospitals still don't let them practice independently. That is not the argument. They won't replace intensivist I agree. But the most APPs are produced and trained they will increase supply and that can decrease demand. You still have an intensivist to over see now 40 pts under 3 APPs than in the past where you come to work, be responsible for your 12-18 patients and be liable only for the patient's you directly see. Hospitals where I work at have no night ICU coverage, they hired a NP as house officer and have an intensivist covering 2-3 community hospitals in an eICU.
Hospital administrators will always see a way to cut physician salary whatever way that's possible but still find someone to take the liability of midlevel Providers.

 

[chessknt]

Though many states have FPA, big name hospitals still don't let them practice independently. That is not the argument. They won't replace intensivist I agree. But the most APPs are produced and trained they will increase supply and that can decrease demand. You still have an intensivist to over see now 40 pts under 3 APPs than in the past where you come to work, be responsible for your 12-18 patients and be liable only for the patient's you directly see. Hospitals where I work at have no night ICU coverage, they hired a NP as house officer and have an intensivist covering 2-3 community hospitals in an eICU.
Hospital administrators will always see a way to cut physician salary whatever way that's possible but still find someone to take the liability of midlevel Providers.

I doubt this. This isn't low liability medicine--these are sick people who often need a high level of attention on a daily basis. No intensivist would assume this kind of liability outside of the disaster that is happening now. It would be like saying a surgeon could be replaced by having midlevels run 12 ors simultaneously and the surgeon could just supervise all of them.

There is no scenario where you wouldn't be liable for patients not seen if an app is working in your icu.

 

[psychbender]

When I was interviewing at an academic practice, a scheduling change meant that I met with the chief critical care NP, rather than one of the other attendings during a block of time on interview day. I remember her telling me to my face that she and her colleagues do everything themselves, and there is nothing that I, as the attending in the unit, add to what she and her colleagues do. Only a surgeon would add anything on top of her abilities, she said. The units where they worked were a 30ish bed neuro ICU (1 attending, ~4-5 NPs) and a general surgical ICU (10-12 beds, one attending and one to two NPs). I have encountered similar attitudes and staffing patterns at other academic centers, as well, so I doubt this was a one-off. I encountered something similar at a private hospital, where there were two teams, each staffed with a physician and a mid-level (usually PA there, due to the presence of a PA school), with the patients on each team divided between the two of them, and the mid-level functioning independently "with some oversight as needed." The proliferation of NP and PA "fellowships" will only exacerbate these situations.

 

[Katheudontas parateroumen]

When I was interviewing at an academic practice, a scheduling change meant that I met with the chief critical care NP, rather than one of the other attendings during a block of time on interview day. I remember her telling me to my face that she and her colleagues do everything themselves, and there is nothing that I, as the attending in the unit, add to what she and her colleagues do. Only a surgeon would add anything on top of her abilities, she said. The units where they worked were a 30ish bed neuro ICU (1 attending, ~4-5 NPs) and a general surgical ICU (10-12 beds, one attending and one to two NPs). I have encountered similar attitudes and staffing patterns at other academic centers, as well, so I doubt this was a one-off. I encountered something similar at a private hospital, where there were two teams, each staffed with a physician and a mid-level (usually PA there, due to the presence of a PA school), with the patients on each team divided between the two of them, and the mid-level functioning independently "with some oversight as needed." The proliferation of NP and PA "fellowships" will only exacerbate these situations.

Wow that’s sad. Also very arrogant. The amount of inferiority complex is high. I would never say that about a fellow “colleague “.

 

[bronx43]

I doubt this. This isn't low liability medicine--these are sick people who often need a high level of attention on a daily basis. No intensivist would assume this kind of liability outside of the disaster that is happening now. It would be like saying a surgeon could be replaced by having midlevels run 12 ors simultaneously and the surgeon could just supervise all of them.

There is no scenario where you wouldn't be liable for patients not seen if an app is working in your icu.

The problem is that you're arguing against the reality which is literally occurring right now across the country. And these trends were mostly in place pre-covid. The only thing the pandemic did was speed up the decay. Most people in this thread have witnessed, trained, or worked at an institution where midlevels run amok with little oversight.

 

[chessknt]

The problem is that you're arguing against the reality which is literally occurring right now across the country. And these trends were mostly in place pre-covid. The only thing the pandemic did was speed up the decay. Most people in this thread have witnessed, trained, or worked at an institution where midlevels run amok with little oversight.

So people on this thread are supervising midlevels and responsible for 40 critically ill patients right now?

 

[bronx43]

So people on this thread are supervising midlevels and responsible for 40 critically ill patients right now?

... have come across rapid midlevel expansion.

You know what? Let’s just revisit this in 5 years. I would love to be wrong.

 

[CCM-MD]

So people on this thread are supervising midlevels and responsible for 40 critically ill patients right now?

No one I know/trained with me is doing this. But that doesn’t mean it’s not happening currently and won’t become more prevalent in the future.

 

[chessknt]

No one I know/trained with me is doing this. But that doesn’t mean it’s not happening currently and won’t become more prevalent in the future.

Well it won't happen if they can't find anyone stupid enough to take that job. I can't envision anyone with ccm training that would due to the risk inherent to the field.

 

[CCM-MD]

Well it won't happen if they can't find anyone stupid enough to take that job. I can't envision anyone with ccm training that would due to the risk inherent to the field.

People to stupid **** for $ all the time.

 

[Matthew9Thirtyfive]

Well it won't happen if they can't find anyone stupid enough to take that job. I can't envision anyone with ccm training that would due to the risk inherent to the field.

There are physicians signing on to be “supervising” physicians for midlevels who are over 150 miles away, essentially being liability sponges while they maim and kill patients, all for some extra coin. What makes you think people won’t do what you’re saying?

 

[blue.jay]

I doubt this. This isn't low liability medicine--these are sick people who often need a high level of attention on a daily basis. No intensivist would assume this kind of liability outside of the disaster that is happening now. It would be like saying a surgeon could be replaced by having midlevels run 12 ors simultaneously and the surgeon could just supervise all of them.

There is no scenario where you wouldn't be liable for patients not seen if an app is working in your icu.

Surgery is a different league and cannot be compared to critical care. You don't hear surgeons letting a midlevel do a laprotomy or teaching them their skill. It's a 5 yr long residency compared to 1-2 yr critical care fellowship which they are trying to bridge the gap with these midlevel critical care residencies.
I guess we are made to feel very important about our skills during residency and fellowship doesn't mean that the real world and MBA overlords value that. If a midlevel can be trained to manage 90% of the cases in 90% of the ICUs in the country they won't stop utilizing them while turfing the liability to superivising tele ICU or intensivist. I agree that midlevels don't have the acumen to run a higher level ICU with ECMO, Impella, Ballonpump, transplant but those are not managed independantly by the intensivists anyways.

I would argue the liability is more for a PCP or hospitalists for not diagnosing illness early which led to admission/rapid response/code blue than for intensivist. Patients and family know that going to ICU is life threatening and there is a chance they might die whereas a patient seeing a PCP for unresolving headache from brain tumor where the PCP didn't scan and tried changing meds will more likely to be sued.

 

[MLNS]

Surgery is a different league and cannot be compared to critical care. You don't hear surgeons letting a midlevel do a laprotomy or teaching them their skill. It's a 5 yr long residency compared to 1-2 yr critical care fellowship which they are trying to bridge the gap with these midlevel critical care residencies.
I guess we are made to feel very important about our skills during residency and fellowship doesn't mean that the real world and MBA overlords value that. If a midlevel can be trained to manage 90% of the cases in 90% of the ICUs in the country they won't stop utilizing them while turfing the liability to superivising tele ICU or intensivist. I agree that midlevels don't have the acumen to run a higher level ICU with ECMO, Impella, Ballonpump, transplant but those are not managed independantly by the intensivists anyways.

I would argue the liability is more for a PCP or hospitalists for not diagnosing illness early which led to admission/rapid response/code blue than for intensivist. Patients and family know that going to ICU is life threatening and there is a chance they might die whereas a patient seeing a PCP for unresolving headache from brain tumor where the PCP didn't scan and tried changing meds will more likely to be sued.

You’re incorrect in one regard

On my GS rotation in med school I saw just that: surgeons teaching their craft to midlevels so that they could run multiple rooms and bill for it. They were also teaching the midlevels more than the residents

 

[blue.jay]

You’re incorrect

On my GS rotation in med school I saw just that: surgeons teaching their craft to midlevels so that they could run multiple rooms and bill for it. They were also teaching the midlevels more than the residents

It is true that surgeons feel more invested in spending time with midlevels who work under them longer than resident/fellows. They don't train them to practice 100% exactly like what they do in a non-surgical speciality. Most midlevel surgery residencies are used for post op rounds and 1st assist. You don't hear a midlevel in surgery say they do the same job as their attending like they do in EM, anesthesia, IM, FM, Peds, Neuro, Psych.

I think surgeons are the only ones who are utilizing midlevels as scutmonkey/perpetual resident for their benefit, spend more time in OR and less time in clinic and post-op rounds. Cognitive specialities are teaching midlevels their trade and letting them encroach our job market.

 

[Señor S]

You’re incorrect in one regard

On my GS rotation in med school I saw just that: surgeons teaching their craft to midlevels so that they could run multiple rooms and bill for it. They were also teaching the midlevels more than the residents

I've seen PAs/NPs assist, close skin and do certain parts of cases (e.g., vein harvesting for CABG). I can absolutely believe that many surgeons would prefer NPs/PAs to residents as well...but I've never seen or heard of a midlevel doing an entire case independently or without a surgeon present for almost all of it. Sounds like Medicare fraud if what you're saying actually happened. You should file a whistleblower complaint; you'd be entitled to a percentage of any money that was recovered

Whistleblower Sheds Light on Dangerous Medicaid Scam

May 5th, 2015 IU Health and HealthNet is accused of scamming government healthcare out of millions of dollars and putting patient safety at risk.

www.whistleblowerinfo.com

 

[CCM-MD]

No field is truly “safe” from encroachment. Though subspecialty surgery is probably the safest of all. CCM is among the easier ones to encroach upon.

 

[chessknt]

Surgery is a different league and cannot be compared to critical care. You don't hear surgeons letting a midlevel do a laprotomy or teaching them their skill. It's a 5 yr long residency compared to 1-2 yr critical care fellowship which they are trying to bridge the gap with these midlevel critical care residencies.
I guess we are made to feel very important about our skills during residency and fellowship doesn't mean that the real world and MBA overlords value that. If a midlevel can be trained to manage 90% of the cases in 90% of the ICUs in the country they won't stop utilizing them while turfing the liability to superivising tele ICU or intensivist. I agree that midlevels don't have the acumen to run a higher level ICU with ECMO, Impella, Ballonpump, transplant but those are not managed independantly by the intensivists anyways.

I would argue the liability is more for a PCP or hospitalists for not diagnosing illness early which led to admission/rapid response/code blue than for intensivist. Patients and family know that going to ICU is life threatening and there is a chance they might die whereas a patient seeing a PCP for unresolving headache from brain tumor where the PCP didn't scan and tried changing meds will more likely to be sued.

The pa is there watching and helping the surgeon the entire case. I don't understand how you think ccm training is any different--I tell nps what to do and they watch how I manage patients on rounds then practice doing it that way on their own.

Anyhow I'm done arguing it is clear that this echo chamber of misery and gloom wants to believe the field of ccm is dead so please have at it.

 

[blue.jay]

The pa is there watching and helping the surgeon the entire case. I don't understand how you think ccm training is any different--I tell nps what to do and they watch how I manage patients on rounds then practice doing it that way on their own.

Anyhow I'm done arguing it is clear that this echo chamber of misery and gloom wants to believe the field of ccm is dead so please have at it.

I don't think CCM is dead and that it's all doom and misery. The roles might change much similar to anesthesia/crna with intensivists doing mostly tele or having some major oversight and Midlevels doing the ground work. Anesthesia job market is great and their salaries are good though they have turf wars.

Also, a PA watching or assisting the surgeon is not the same as observing and learning the practice in a cognitive speciality like CCM. I watch 1000s of piano/guitar videos but still can't play the instrument without actually practicing my fine motor skills. Surgery/endoscopy/laproscopy is a fine motor skill which someone has to do to learn and watching is not enough. Midlevels cannot become surgeons by watching or doing skin closure.

 

[CCM-MD]

I don't think CCM is dead and that it's all doom and misery. The roles might change much similar to anesthesia/crna with intensivists doing mostly tele or having some major oversight and Midlevels doing the ground work. Anesthesia job market is great and their salaries are good though they have turf wars.

Also, a PA watching or assisting the surgeon is not the same as observing and learning the practice in a cognitive speciality like CCM. I watch 1000s of piano/guitar videos but still can't play the instrument without actually practicing my fine motor skills. Surgery/endoscopy/laproscopy is a fine motor skill which someone has to do to learn and watching is not enough. Midlevels cannot become surgeons by watching or doing skin closure.

Surgery? It’s not rocket science. Again, CCM isn’t the only thing being encroached upon. Everything is.

Nurses to be trained to perform surgery to ease waiting times

They will be able to perform procedures such as removing hernias, benign cysts and some skin cancers.

www.google.com

Redirect Notice

Meet the nurse who will soon perform surgery on patients alone

Unlike other nursing roles, a surgical care practitioner is involved with the patient every step of the way

www.google.com

 

[blue.jay]

I tell nps what to do and they watch how I manage patients on rounds then practice doing it that way on their own

That's how it starts because they aren't prepared to practice right out of their mediocre schooling. These NPs will eventually start doing their own **** and become autonomous when you are liable. My employer (well known academic center) says that midlevels with >5 yrs of experience are as good as attendings and should be given complete autonomy.

Most midlevels (non-surgical) don't want to be forever residents. Their training is subpar but once they get into the groove these employers hold on to them preferentially because they are so much cheaper and do the same work as a board certified EM/hospitalist/intensivist.

 

[Matthew9Thirtyfive]

My employer (well known academic center) says that midlevels with >5 yrs of experience are as good as attendings and should be given complete autonomy.

This is despicable.

 

[MLNS]

I've seen PAs/NPs assist, close skin and do certain parts of cases (e.g., vein harvesting for CABG). I can absolutely believe that many surgeons would prefer NPs/PAs to residents as well...but I've never seen or heard of a midlevel doing an entire case independently or without a surgeon present for almost all of it. Sounds like Medicare fraud if what you're saying actually happened. You should file a whistleblower complaint; you'd be entitled to a percentage of any money that was recovered

Whistleblower Sheds Light on Dangerous Medicaid Scam

May 5th, 2015 IU Health and HealthNet is accused of scamming government healthcare out of millions of dollars and putting patient safety at risk.

www.whistleblowerinfo.com

Interesting. Was not aware re: whistleblowing. I literally watched the np do the entire lap chole with the surgeon, ironically, opening the skin only

I was beyond perplexed at the time

 

[Matthew9Thirtyfive]

Interesting. Was not aware re: whistleblowing. I literally watched the np do the entire lap chole with the surgeon, ironically, opening the skin only

I was beyond perplexed at the time

Holy **** that place needs to be named and shamed.

 

[Señor S]

The pa is there watching and helping the surgeon the entire case. I don't understand how you think ccm training is any different--I tell nps what to do and they watch how I manage patients on rounds then practice doing it that way on their own.

Anyhow I'm done arguing it is clear that this echo chamber of misery and gloom wants to believe the field of ccm is dead so please have at it.

In surgery the requirement/expectation is that the attending is there, physically in the room, for almost the entire case. Very different from the situation in many ICUs where the attending is on "home call" and the APP is told to handle things independently "if she feels comfortable." 14 hours might pass before an actual board-certified physician sets foot in that ICU. Not a huge jump from that to 24/7 "eICU" coverage which will mostly act as a liability sponge, which the APPs will rarely (if ever) actually utilize and which as a result will allow one Critical Care physician to "cover" god-only-knows how many ICUs and ICU patients.

 

[thorwayCC]

In surgery the requirement/expectation is that the attending is there, physically in the room, for almost the entire case. Very different from the situation in many ICUs where the attending is on "home call" and the APP is told to handle things independently "if she feels comfortable." 14 hours might pass before an actual board-certified physician sets foot in that ICU. Not a huge jump from that to 24/7 "eICU" coverage which will mostly act as a liability sponge, which the APPs will rarely (if ever) actually utilize and which as a result will allow one Critical Care physician to "cover" god-only-knows how many ICUs and ICU patients.

Thats the current requirement. Just like for the ICU, the requirement that physician was in the unit doing the job few years ago.. Things change.

 

[Señor S]

Thats the current requirement. Just like for the ICU, the requirement that physician was in the unit doing the job few years ago.. Things change.

Could be, but imo less likely. Surgery is just different; it has an aura with the general public that is unlike anything else in medicine. I think nurses doing surgery is something a lot of people will refuse to accept. The aggressive, pushy surgical personality will help them fend off incursions too. And really, I don't know how much APPs even want to do surgery. The type of person who becomes an NP or PA might want to do a CVL or intubate, but take out a gallbladder?

If anything it seems like the trend is for CMS/the courts/the public to want even more direct involvement of surgeons in their cases, and to chastise/punish those who deviate:

Manhattan U.S. Attorney Announces $12.3 Million Settlement With Lenox Hill Hospital For Submitting Fraudulent Medicare Claims For Urology Procedures And Hospital Services

www.justice.gov

Mass General, Northwell Health pay millions to settle concurrent surgery suits

Boston-based Massachusetts General Hospital and New Hyde Park, N.Y.-based Northwell Health have agreed to pay millions of dollars to resolve lawsuits related to the practice of double-booking surgeries, The Boston Globe reports.

www.beckershospitalreview.com