Conflict with NPs on my team - how to manage?

[kidthor]

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I'm a resident on a rotation that has a team structure where there's a resident and an NP each managing an equal number of patients, and then an attending overseeing us both. The residents are on q4 24 hour call and the NPs work 12 hour shifts... I've had a lot of conflict with the NPs inventing "rules" that benefit themselves and trying to manage outside of their purview. For example, we have a medical student with us and our NP has told us that they (the NPs) are in charge of assigning patients to the med students, and that the residents can't manage them - we've gotten into arguments during rounds over this in fact. I've also had issues with the NP trying to sign out earlier than the established time and explaining that "this is how we do things" (note of course that I'm in the 24 hour person on call, so this will never be a reciprocal issue - as in I'd NEVER be able to sign out early). I also have issues with the NPs speaking over me during rounds during my presentations or disagreeing with my management strategies.

I realize that residents often just have to keep their heads down and not make too much noise. But it seems like there are too often issues where midlevels are able to take advantage of us, as we rotate through certain services where they are a constant fixture. I've made some comments to some of the higher-ups about the issues I'm having, and suggested that some concrete policies would resolve some of these issues. The thing that bothered me most was the NP telling the med student what patients they'd be assigned to (and of course the med student was assigned NP patients, seemingly in an attempt for the NP to offload work onto him)... and then arguing with me about it.

Have any of you had similar issues? Do you think it's worth discussing these things with your leadership to get changes made, at the expense of possibly muddying up an already toxic environment?

 

[deleted480308]

you alreadyasked the attendings....nothing happened.

keep your head down and your attending happy, that's all that matters

 

[Bacchus]

Unfortunately I think you just have to keep your head down. The only thing you have control over is sign out. If you're asked to sign out early, than avoid sign out. It's passive agressive, it makes you look like an dingus, but if that's established already then you're not violating anything. Then again, it may make the day more bearable if the NP is out of your hair.

 

[HooliganSnail]

Honestly, everyone knows when bullsh*t is occuring.

Show up everyday. Work hard. If the NP dumps work onto you just handle it without complaining. It may not seem like people notice or care, but everyone sees you. They see how you respond, how you interact. They notice that you never complain and just get your work done.

On another note, it may seem like the NP is dumping work off on the medical student, but in reality every patient that a medical student sees for you becomes your responsibility to take time and go through that patient with them. If you are not doing that, then you are not being a proper teacher. If the NP is using the medical students, then the medical students will complain, and remember that NO ONE can complain like a medical student. (It would have really pissed me off to be taught by an NP as a medical student, like the money I pay in tuition can't even get me a physician as a clinical preceptor.)

 

[rokshana]

and when the NP starts talking over you during presentation….just stop talking and let him/her finish talking(cuz you're being polite and letting them have their say)….and once (s)he stops, then resume your presentation…eventually your silence will be noticeable and hopefully they will stop talking.

and as for the med student being assigned to the NP…well I think the gripe probably should be best addressed by the med student if they are unhappy with having an NP supervise them…

its one rotation that last a few weeks…how many times will you be on service with them? just keep your head down and get through it (and like bacchus said be available for sign out when you are supposed to be available for sign out…what are they gonna do? complain that they can't leave early??).

 

[gutonc]

Agree with the others here. Head down, get work done, don't rock the boat. This is the way they do it. Right or wrong, you're not going to change the culture in 2-4 weeks. But you can seriously f*** yourself if you try.

If the NP is interfering with your education or patient care, bring it up with your PD.

And I'll disagree with one thing above. @HooliganSnail said nobody can complain like a med student. Clearly, s/he has never met an NP.

 

[Gastrapathy]

This is probably an ACGME violation for service responsibilities for non-teaching patients. If you can't find another way to complain, this is what the anonymous survey is for.

Medical students working for NPs is incredibly weak sauce but that's not your problem. If you think they make you faster, you aren't doing it right.

 

[NotAProgDirector]

I'm assuming this isn't an IM rotation / residency by your tagline of "ASA member". In IM, this would be an ACGME violation -- residents are not allowed to cover non teaching (i.e. NP) patients at night if they don't have primary responsibility for them during the day.

You can either put up with it, or discuss it with your PD.

 

[nlax30]

What sort of service are you on that has this structure?

 

[HooliganSnail]

Agree with the others here. Head down, get work done, don't rock the boat. This is the way they do it. Right or wrong, you're not going to change the culture in 2-4 weeks. But you can seriously f*** yourself if you try.

If the NP is interfering with your education or patient care, bring it up with your PD.

And I'll disagree with one thing above. @HooliganSnail said nobody can complain like a med student. Clearly, s/he has never met an NP.

HA!!! That seriously just made my night

 

[ThoracicGuy]

I'm a resident on a rotation that has a team structure where there's a resident and an NP each managing an equal number of patients, and then an attending overseeing us both. The residents are on q4 24 hour call and the NPs work 12 hour shifts... I've had a lot of conflict with the NPs inventing "rules" that benefit themselves and trying to manage outside of their purview. For example, we have a medical student with us and our NP has told us that they (the NPs) are in charge of assigning patients to the med students, and that the residents can't manage them - we've gotten into arguments during rounds over this in fact. I've also had issues with the NP trying to sign out earlier than the established time and explaining that "this is how we do things" (note of course that I'm in the 24 hour person on call, so this will never be a reciprocal issue - as in I'd NEVER be able to sign out early). I also have issues with the NPs speaking over me during rounds during my presentations or disagreeing with my management strategies.

I realize that residents often just have to keep their heads down and not make too much noise. But it seems like there are too often issues where midlevels are able to take advantage of us, as we rotate through certain services where they are a constant fixture. I've made some comments to some of the higher-ups about the issues I'm having, and suggested that some concrete policies would resolve some of these issues. The thing that bothered me most was the NP telling the med student what patients they'd be assigned to (and of course the med student was assigned NP patients, seemingly in an attempt for the NP to offload work onto him)... and then arguing with me about it.

Have any of you had similar issues? Do you think it's worth discussing these things with your leadership to get changes made, at the expense of possibly muddying up an already toxic environment?

One problem with having an NP is that they are there all the time. As a resident, you are there maybe every 4-6 weeks, then you change. The NP is a constant that the attending sees and deals with on a daily basis. They will tend to be biased towards the NP at the resident expense. The NP has a chance to really know what nuances are there for each attending that you'll never really get in 4-6 weeks. Just keep your head down, avoid a big fight, and get through the rotation.

As people have said before, they can't stop the clock...

 

[michaelrack]

Agree with what others are saying- the OP will probably need to give in on most issues, but I do think that the medical students being supervised by the NP is a problem that should be fixed (not necessarily by the resident, this should probably be fixed through different channels)

 

[core0]

I'm a resident on a rotation that has a team structure where there's a resident and an NP each managing an equal number of patients, and then an attending overseeing us both. The residents are on q4 24 hour call and the NPs work 12 hour shifts... I've had a lot of conflict with the NPs inventing "rules" that benefit themselves and trying to manage outside of their purview. For example, we have a medical student with us and our NP has told us that they (the NPs) are in charge of assigning patients to the med students, and that the residents can't manage them - we've gotten into arguments during rounds over this in fact. I've also had issues with the NP trying to sign out earlier than the established time and explaining that "this is how we do things" (note of course that I'm in the 24 hour person on call, so this will never be a reciprocal issue - as in I'd NEVER be able to sign out early). I also have issues with the NPs speaking over me during rounds during my presentations or disagreeing with my management strategies.

I realize that residents often just have to keep their heads down and not make too much noise. But it seems like there are too often issues where midlevels are able to take advantage of us, as we rotate through certain services where they are a constant fixture. I've made some comments to some of the higher-ups about the issues I'm having, and suggested that some concrete policies would resolve some of these issues. The thing that bothered me most was the NP telling the med student what patients they'd be assigned to (and of course the med student was assigned NP patients, seemingly in an attempt for the NP to offload work onto him)... and then arguing with me about it.

Have any of you had similar issues? Do you think it's worth discussing these things with your leadership to get changes made, at the expense of possibly muddying up an already toxic environment?

As a PA that works with residents, our job is to off load patients to allow the attendings to teach. We don't off load onto residents. As for medical students, the education of medical students is the purview of physicians. I am happy to explain a procedure or why we do things, but they are here to learn to be physicians and physicians should be the one teaching them. The one suggestion I have, is our residents give feedback to the residency director who then talks to our medical director (I think this is required by the RCC). On our service this is a one way communication that lets us improve things that the residents find lacking. There is no blow back because the residents don't come back after they give their feedback. If the OP is in a situation where he can give feedback without retribution this might be helpful especially regarding the medical students.

 

[FutureInternist]

Do the daily work as is
Wait to get good evals (so they can't screw you over) & then skewer them on the yearly evaluations

 

[QofQuimica]

Do you think it's worth discussing these things with your leadership to get changes made, at the expense of possibly muddying up an already toxic environment?

Is your goal in life to be a BE/BC physician, or is it to be a martyr? If it's the former, then the answer is no. In a few weeks, these people will cease to matter as far as you're concerned. Suck it up for the rest of the rotation and then move on with your life.

 

[Top Gun]

While I agree the OP has no choice but to suck it up and take whatever crap the NPs dish out, it really does burn my butt that this sort of thing is allowed to occur. Not only are we, as a group, allowing NP's to encroach on our profession, but now we have to kowtow to them as well (at least, in residency), even when they are being downright rude by interrupting us during presentations and screwing us over.

 

[DermViser]

While I agree the OP has no choice but to suck it up and take whatever crap the NPs dish out, it really does burn my butt that this sort of thing is allowed to occur. Not only are we, as a group, allowing NP's to encroach on our profession, but now we have to kowtow to them as well (at least, in residency), even when they are being downright rude by interrupting us during presentations and screwing us over.

You realize that her attending is facilitating this right? It's not at all surprising that an attending would take the side of an NP who has been there a long time vs. an intern/resident.

 

[deleted480308]

You realize that her attending is facilitating this right? It's not at all surprising that an attending would take the side of an NP who has been there a long time vs. an intern/resident.

exactly...come september that NP will still be there every day and the resident will have left the rotation. As people tend to take the path of least resistance the attending can either tick off someone they will see for years everyday or the someone who leaves in 2 weeks

OP has already figured out the attending's choice

 

[DermViser]

exactly...come september that NP will still be there every day and the resident will have left the rotation. As people tend to take the path of least resistance the attending can either tick off someone they will see for years everyday or the someone who leaves in 2 weeks

OP has already figured out the attending's choice

That's the problem in residencies like these in which you have so called "team-based" care: it's the attending, the resident, the interns, the medical students, social worker, the NP, etc. You can't call out anyone's incompetence, except for yours, of course.

As an intern, you are still at the bottom. If the OP complains about this NP (which is deserved), it's much easier to throw the intern under the bus than the NP (who likely has some nursing union lobby).

 

[DermViser]

Honestly, everyone knows when bullsh*t is occuring.

Show up everyday. Work hard. If the NP dumps work onto you just handle it without complaining. It may not seem like people notice or care, but everyone sees you. They see how you respond, how you interact. They notice that you never complain and just get your work done.

On another note, it may seem like the NP is dumping work off on the medical student, but in reality every patient that a medical student sees for you becomes your responsibility to take time and go through that patient with them. If you are not doing that, then you are not being a proper teacher. If the NP is using the medical students, then the medical students will complain, and remember that NO ONE can complain like a medical student. (It would have really pissed me off to be taught by an NP as a medical student, like the money I pay in tuition can't even get me a physician as a clinical preceptor.)

The job of the medical student isn't to see the patient FOR the intern. Interns that rely on medical students to do their work for them will get easily burned and this will be exposed on rounds and your upper level will call you out on it.

Also, the intern's contract/job description is not to "teach" the medical student. It's to get the work done. Actual teaching is for the upper level.

 

[Armadillos]

As a medstudent I really don't have a problem with being "taught" by a NP/PA in this context, when there is still an attending rounding/teaching every morning. During the day when the attendings disappear, if Im working with some PA/NP thats been working in cards/GI/Ortho/whatever specialty for 10 years, they are going to be 100x better at teaching than the interns and depending on the situation are likely better at teaching in that specific sub-specialty than the upper level resident. I would obviously not feel this way if there was no attending involved though.

 

[QofQuimica]

While I agree the OP has no choice but to suck it up and take whatever crap the NPs dish out, it really does burn my butt that this sort of thing is allowed to occur. Not only are we, as a group, allowing NP's to encroach on our profession, but now we have to kowtow to them as well (at least, in residency), even when they are being downright rude by interrupting us during presentations and screwing us over.

Picking one's battles is a crucial skill for residents to learn. I think its safe to say that July of your intern year is not the best time to start fighting the man.

 

[AStark]

As a medstudent I really don't have a problem with being "taught" by a NP/PA in this context, when there is still an attending rounding/teaching every morning. During the day when the attendings disappear, if Im working with some PA/NP thats been working in cards/GI/Ortho/whatever specialty for 10 years, they are going to be 100x better at teaching than the interns and depending on the situation are likely better at teaching in that specific sub-specialty than the upper level resident. I would obviously not feel this way if there was no attending involved though.

I don't know what phase of training you're in, but I can take from this that you haven't worked with many NPs. There are some great, knowledgeable ones, but often they function more as permanent junior housestaff doing a lot of scut in routine, often post-op situations, and consult for everything else. As a resident I present some sort of formal teaching at least once a block, and I do informal teaching with med students all the time.

 

[SouthernSurgeon]

I don't know what phase of training you're in, but I can take from this that you haven't worked with many NPs. There are some great, knowledgeable ones, but often they function more as permanent junior housestaff doing a lot of scut in routine, often post-op situations, and consult for everything else. As a resident I present some sort of formal teaching at least once a block, and I do informal teaching with med students all the time.

Yup.

Our experienced PAs are great. They've been on the same service for years. They know that Dr. XXX likes to advance the diet to clears on POD2. They know that Dr. YYY doesn't like toradol. They know the name of the scheduler in radiology to make sure our patients get their upper GIs first thing in the morning. They know which endocrinologist consults on the bariatric patients. Etc. Etc.

They do an awesome job and they help our services run smoothly.

But they don't know a lot of the pathophsyiology. They don't know surgical indications. They are good at teaching tasks and good at teaching intern/efficiency skills.

They are not a replacement for resident and (especially) attending teaching.

 

[eastcoastdr]

Pretty much agree with everyone else. Keep your head down and be the bigger person. Okay, so the NP signs out too early, talks over you in presentations, and steals medical students from you...yes that's annoying but you also don't want to peg yourself as someone who complains and throws a fit over little things. I think there are diplomatic ways of handling this rather than complaining to upper levels. Also I bet your attending has much more important things to worry about than this.

If they sign out too early, say you are busy with patient care/phone call/whatever but you'd be more than happy to take sign out at the usual time. If they talk over you or disagree with your presentation, take it calmly, don't argue in rounds and say something like "I appreciate your input, but is it okay if I finish the rest of my presentation and we can discuss it at the end?" If they steal a medical student from you, you could politely ask "Hey I would like a chance to work with a student too, I haven't gotten much chance to do any teaching yet, is it okay if they work with me today?" The NP on your team may be rude and selfish but I think the right approach would be to A) ignore like everyone said or B) if you really have to do something, speak to this person in a professional manner. Maybe they just haven't worked with residents that care about this stuff before so they assume they can do whatever they want. If they are uncooperative, well then you may be SOL. There will always be people that are just hard to work with!

 

[dozitgetchahi]

One problem with having an NP is that they are there all the time. As a resident, you are there maybe every 4-6 weeks, then you change. The NP is a constant that the attending sees and deals with on a daily basis. They will tend to be biased towards the NP at the resident expense. The NP has a chance to really know what nuances are there for each attending that you'll never really get in 4-6 weeks. Just keep your head down, avoid a big fight, and get through the rotation.

As people have said before, they can't stop the clock...

Dear god, I experienced some of this at one of our hospitals that we don't spend much time at.

This was ICU, and our pericular service (one of 5-6 CCM teams-huge hospital) was 'fortunate' to have the NPs that month. The NPs did the most disruptive **** with regards to patient care...they called consults on my pts without telling me and would walk around and tell the nurses after rounds to page them (and not me) with concerns. One day a patient of mine developed chest pain and went to the cath lab without me hearing a peep about it...the NP had made all of the decisions and done all of it.

Totally echo the fact that the NPs get taken more seriously because they're there constantly while you're there for a few weeks, tops. It's total BS, but you're unlikely to be able to do much about it.

 

[deleted480308]

slightly related story...was talking medical training with someone lately and a mutual friend who happened to be nearby started talking about how annoying it was to train residents in the OR because they didn't know anything and got in the way. Find out later, she's a RN...awesome

 

[dozitgetchahi]

slightly related story...was talking medical training with someone lately and a mutual friend who happened to be nearby started talking about how annoying it was to train residents in the OR because they didn't know anything and got in the way. Find out later, she's a RN...awesome

Oh yeah. Whenever nurses start whining about things like this, I usually say something like 'well YOU were a trainee once too, right? Do you remember how clueless and small you felt? Didn't you rely on the kindness and patience of your superiors to help you learn the ropes? Didn't you hate it when some people treated you like garbage JUST BECAUSE you were a trainee? That didn't feel so good, did it?'

When that doesn't work, I simply say that the alternative is to not train any more new doctors. That'll work great, won't it?

 

[evilbooyaa]

Oh yeah. Whenever nurses start whining about things like this, I usually say something like 'well YOU were a trainee once too, right? Do you remember how clueless and small you felt? Didn't you rely on the kindness and patience of your superiors to help you learn the ropes? Didn't you hate it when some people treated you like garbage JUST BECAUSE you were a trainee? That didn't feel so good, did it?'

When that doesn't work, I simply say that the alternative is to not train any more new doctors. That'll work great, won't it?

I'm sure there is a very small subset of RNs/NPs that would be OK with that sentiment. NPs for everybody.

 

[Top Gun]

I'm sure there is a very small subset of RNs/NPs that would be OK with that sentiment. NPs for everybody.

Yeah, in residency, an ER nurse told me that NPs can pretty much do anything a doctor can do and might be replacing doctors in the future, and told me to think about that.

 

[ChessMaster3000]

This is the sort of issue I'd take to the chief resident, but generalize it to NP vs resident care of "non-teaching" patients so it doesn't sound like you are implicating your attending for not handling the situation

 

[Gastrapathy]

What would you like the chief resident to do? Call the attending and say "some anonymous resident who you've observed not getting along with the nurses and is on service right now is unhappy?

 

[VisionaryTics]

I learned a new type of nursing alphabet soup last month: the RNFA (Registered Nurse First Assistant). I don't know how these people are trained, but it apparently involves a daily "Two Minutes Hate" a la 1984 using pictures of residents.

Just a relentlessly hostile OR environment...

 

[DermViser]

I learned a new type of nursing alphabet soup last month: the RNFA (Registered Nurse First Assistant). I don't know how these people are trained, but it apparently involves a daily "Two Minutes Hate" a la 1984 using pictures of residents.

Just a relentlessly hostile OR environment...

Aided and abetted by the surgery attendings?

 

[DermViser]

What would you like the chief resident to do? Call the attending and say "some anonymous resident who you've observed not getting along with the nurses and is on service right now is unhappy?

Um, yeah. He's a millenial and his feelings should be respected. (drops mic and runs)

 

[VisionaryTics]

Aided and abetted by the surgery attendings?

No. Attendings would usually give me a heads up if certain RNFAs were scrubbing. And the claws would really come out when he said, "VisionaryTics, close" and leave the room.

 

[DermViser]

No. Attendings would usually give me a heads up if certain RNFAs were scrubbing. And the claws would really come out when he said, "VisionaryTics, close" and leave the room.

Did you tell the attending?

 

[VisionaryTics]

Did you tell the attending?

He was giving me a heads up because he knew. During the operation, he would be pretty direct: "RNFA, take a break and let VisionaryTics do XYZ", but once he was out of the room the low-grade hostility got taken up a notch. Whatever. Off that service.

 

[DermViser]

He was giving me a heads up because he knew. During the operation, he would be pretty direct: "RNFA, take a break and let VisionaryTics do XYZ", but once he was out of the room the low-grade hostility got taken up a notch. Whatever. Off that service.

I'm just surprised the surgeon wouldn't go higher up to get the RNFA fired, but I guess his hands are tied with respect to employment.

 

[bambi]

Yeah, in residency, an ER nurse told me that NPs can pretty much do anything a doctor can do and might be replacing doctors in the future, and told me to think about that.

During our version of intern year an ANP once told a group of about 20 of us that she learnt in her 2 year course what we learnt in 5 years of medical school so she was better than us. When she then tried to teach us something it was pretty clear that her grasp of anything even remotely medical was absolutely minimal.

 

[dozitgetchahi]

During our version of intern year an ANP once told a group of about 20 of us that she learnt in her 2 year course what we learnt in 5 years of medical school so she was better than us. When she then tried to teach us something it was pretty clear that her grasp of anything even remotely medical was absolutely minimal.

Oh yes, the CCM NPs dropped a couple doozies when I was on the service as well.

One day I overheard one asking the attending why we were trying to culture S. pneumo in a pts urine - how did this relate to his pneumonia? The notion that we were looking for a urinary antigen was completely foreign to her.

 

[FutureInternist]

I'm a resident on a rotation that has a team structure where there's a resident and an NP each managing an equal number of patients, and then an attending overseeing us both. The residents are on q4 24 hour call and the NPs work 12 hour shifts... I've had a lot of conflict with the NPs inventing "rules" that benefit themselves and trying to manage outside of their purview. For example, we have a medical student with us and our NP has told us that they (the NPs) are in charge of assigning patients to the med students, and that the residents can't manage them - we've gotten into arguments during rounds over this in fact. I've also had issues with the NP trying to sign out earlier than the established time and explaining that "this is how we do things" (note of course that I'm in the 24 hour person on call, so this will never be a reciprocal issue - as in I'd NEVER be able to sign out early). I also have issues with the NPs speaking over me during rounds during my presentations or disagreeing with my management strategies.

I realize that residents often just have to keep their heads down and not make too much noise. But it seems like there are too often issues where midlevels are able to take advantage of us, as we rotate through certain services where they are a constant fixture. I've made some comments to some of the higher-ups about the issues I'm having, and suggested that some concrete policies would resolve some of these issues. The thing that bothered me most was the NP telling the med student what patients they'd be assigned to (and of course the med student was assigned NP patients, seemingly in an attempt for the NP to offload work onto him)... and then arguing with me about it.

Have any of you had similar issues? Do you think it's worth discussing these things with your leadership to get changes made, at the expense of possibly muddying up an already toxic environment?

Just remembered that the ACGME service asks Qs about non-resident people getting in the way of your training, so you have that to look forward to since once it shows up there, the admins have to address it

 

[Armadillos]

As an aside, I just got off a service that had a full time NP in addition to several interns and an upper level resident. NP and upper level resident did the same job essentially, each for half the service. It worked incredibly well, the NP could help everybody with any sort of idiosyncratic logistical stuff related to the specific service, was really knowledgeable about various followup issues specific to the service, etc. Saved the interns from the inevitable hour long wild goose chases of figuring out exactly who they need to get on the phone to fix X trivial problem/situation. Overall seemed to make for a much better experience for everyone, so I think there are definitely ways were the mixed team setup can be beneficial to residents/interns.