APP scope creep

[clubdeac]

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How do you guys feel about this article published in Chest

 

[tartesos]

I have never seen one do it or wanting to do it.

They can take my bronchoscope out of my cold dead fingers 🤣

 

[joooul]

This article seems to be written by chatgpt. Bronchoscopy is merely the tip of the iceberg. An increasing amount of 'literature' equates CCM physicians with NPs/PAs in different ICU settings( nighttime, specialized units, and step-down). I won't be surprised if, in the next decade, NPs and PAs constitute the majority of ICU 'providers,' a change that would also be reflected in compensation and align with Medicare/Medicaid goals.

 

[CCM-MD]

I've worked with a few ICU midlevels "signed off" with bronchs. Mostly snot sucking with an airway in place. I’ve also met a couple that an idiot surgeon decided to train in perc trachs and they love to brag about it. Medicine is in a sad state.

 

[chessknt]

The bronchoscope in the picture looks like a pediatric scope. WTF are they going to do with that?

 

[clubdeac]

This article seems to be written by chatgpt. Bronchoscopy is merely the tip of the iceberg. An increasing amount of 'literature' equates CCM physicians with NPs/PAs in different ICU settings( nighttime, specialized units, and step-down). I won't be surprised if, in the next decade, NPs and PAs constitute the majority of ICU 'providers,' a change that would also be reflected in compensation and align with Medicare/Medicaid goals.

Wow so you suspect pulm/cc docs will be replaced by midlevels in the next decade? Seems like a highly specialized field requiring intensive training to just be replaced by mid levels

 

[joooul]

I do not believe intensivists will be completely replaced. The main dilemma for stakeholders is, if non-physician providers, are able to provide similar care—as suggested by some non-randomized studies—what staffing and compensation models would be most appropriate to reflect that change?

This is already occurring. For instance, in a 40-bed ICU, instead of having three daytime intensivists, a model might utilize an NP, working under supervision. One can extend this logic and ask, "Why do I need to pay for two intensivists to staff this ICU when I can hire one intensivist to work with three NPs to cover a similar unit?" This can be iterated until an intensivist supervises a theoretical maximum number of NPs. This model was never sold as a replacement; it was initially presented as "augmentation" and "support" (e.g. just let NP do this IJ).

One might argue that this situation is not significantly different from the anesthesiologist-CRNA model and that critical care is simply years behind and the glory awaits us with 500$ per hour. However, the answer is that the scalability of ICUs is very limited compared to ambulatory surgical centers or increasing surgical volumes within a hospital, hence there's increasingly more labor supply for ICU market.

Furthermore, in my opinion that the majority of ICUs (with the exception of CT, CV, and certain neuro) are negative-margin services. Why would an institution expand a negative-margin service unless it is absolutely necessary? One can observe academic medical centers with ICU bed occupancy at nearly 100% and persistent patient boarding in the emergency department; clearly, even this does not pressure leadership to open more ICU beds. It is more likely to see the opening of a step-down unit, which operates under a very different staffing model( hospitalists managing patients with SOFA predicted mortality 20% +). Why would wRVUs be increased for ICU procedures that can be performed by a NP with a one-year online degree?

The question at this point is how far and deep this trend can go and what future ICU staffing models will look like. I do not foresee many positive outcomes unless regulators more heavily penalize poor-quality emergent care. Implementing more metrics that link high-quality critical care to increased financial remuneration for the hospital is one of the principal factors that could restore some balance, may be. I can see intensivists to be shifting for positive-margin ICUs where the involvement from other specialties more common and the raw skill can be observed by others, and hopefully, valued.

 

[grt398]

The question at this point is how far and deep this trend can go and what future ICU staffing models will look like. I do not foresee many positive outcomes unless regulators more heavily penalize poor-quality emergent care. Implementing more metrics that link high-quality critical care to increased financial remuneration for the hospital is one of the principal factors that could restore some balance, may be. I can see intensivists to be shifting for positive-margin ICUs where the involvement from other specialties more common and the raw skill can be observed by others, and hopefully, valued.

This is what worries me these days as an attending working in a physician-only community ICU...as a fellow I worked in a "satellite" ICU run mostly by mid-levels, and there were no consequences for when they provided objectively poor care. An attending even told me they were brought in on-site b/c the mortality level had reached such high levels (think 40%+ mortality in a community ICU) that the hospital couldn't ignore it anymore; it had previously been a fully mid-level run ICU with "supervision" via tele-ICU consults. And I've seen multiple jobs over the past year that have a single attending covering 40+ ICU beds, sometimes with mid-level support, sometimes without. It's crazy.

I have no interest in being forced to supervise an untrained mid-level who works for the hospital and I have no real control over. I've seen them completely ignore attending orders b/c they believed their judgement was better, and no consequences ever happened. It's disheartening frankly and also why I'm living a relatively modest lifestyle and saving as much as I can up front in case things get worse. As much as I dislike much of the regulation in medicine, the fact that no one seems to monitor and if need be penalize poor-quality ICU care is problematic.