Independent Practice Guidelines

[joeDO2]

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So with all the talk of midlevels practicing independently, there has been much discussion over the differences between a new grad and an experienced clinician. I was wondering what you all think should be the requirements for independent practice (i.e. no supervising physician onsite for consultation)? How many years experience, etc. Especially interested to hear from practicing midlevels themselves. Also- I have heard of independent practice in IM, FM, Peds, psychiatry, and EM so far. Are there certain specialties you think should be protected from independent practice or others you have heard of?

 

[Paseo Del Norte]

I am not a mid level provider; however, my opinion is that totally independant practice of medicine is what physicians are prepared to do. I'm not sure it needs to be any more complicated than that. I am a very experienced clinician with well over a decade of pre-hospital, nursing and respiratory therapy experience. I am reasonably intelligent and have even taken some science classes. With that, I'm not convinced a couple years of school would somehow mold me into a safe, independant practitioner. While I have experience, the bottom line is that experience is not medical in the sense that I've been the one making the difficult calls and the decisions. Doesn't mean I'm a bad guy, stupid or a bad provider, just not a practitioner of medicine. Perhaps my uneducated opinion would magically change after a couple years of school.

 

[deleted6669]

I don't think you can make blanket statements about a pa/np being able to work without a doc on site after x years. it will be highly variable depending on the individual and their background.
folks with significant prior experience in the specialty(say medics or er rn's for EM) will probably be ready sooner than new grads with no prior experience or grads of direct entry programs. some folks may never be ready.
some folks are really into medicine and spend all their free time attending conferences, reading journals, volunteering on medical missions, learning new procedures, etc.
some folks(both docs and pa/np's) consider medicine to be just a job and do the very min to get by.
it really depends on who we are talking about.
ps "independent practice" means different things to different folks. pa's never "practice independently", we can practice with off-site supervision and a physician available 24/7 by phone for consults. even a pa working "solo" in alaska or antarctica has a sponsoring physician of record who they can contact at any time who is responsible for reviewing their practice of medicine.
to np's "independent practice" means no formal relationship with a physician at all.
I believe the independent and unsupervised practice of medicine should be granted to residency trained/boarded physicians only.

 

[joeDO2]

I don't think you can make blanket statements about a pa/np being able to work without a doc on site after x years. it will be highly variable depending on the individual and their background.
folks with significant prior experience in the specialty(say medics or er rn's for EM) will probably be ready sooner than new grads with no prior experience or grads of direct entry programs. some folks may never be ready.

then how do we assess competency / readiness to practice solo? I suppose you could do standardized testing, but we all have seen people who are able to ace tests and still be total clowns.

 

[deleted6669]

then how do we assess competency / readiness to practice solo? I suppose you could do standardized testing, but we all have seen people who are able to ace tests and still be total clowns.

like I said it has to be an individual evaluation. in my group no one gets cleared to work solo regardless of their prior experience. the chief of the dept has to work with you one on one for an extended period of time and review 100% of your charts before you are cleared to work alone. for most experienced folks this works out to at least a year of closely supervised practice after joining the group. the chief also checks with other docs, pa's, and nurses to make sure they are making the right recommendation.
I worked in other em jobs for 5 years and at my current job for a year before being cleared to work solo. I also had plenty of prior experience as a paramedic and paramedic instructor before this.
ps: I think standardized specialty testing is a good idea as well but it can't be the only criteria. there is a national specialty exam for pa's in emergency medicine now. I am the only pa at any of my jobs to take and pass it.

 

[deleted87716]

If you're a PA, you are never "working solo." You are always working under a physician's license, and the buck ultimately stops with them, from a medicolegal standpoint. Any quasi-independence you are afforded merely reflects their comfort with their own ultimate liability. In the hospital setting, this is typically mired in institutional bureaucracy and beyond the control of the individual supervising physician.

Any discussion of mid-level "independence" should be restricted to nurse practitioners.

 

[deleted6669]

If you're a PA, you are never "working solo." You are always working under a physician's license, and the buck ultimately stops with them, from a medicolegal standpoint. Any quasi-independence you are afforded merely reflects their comfort with their own ultimate liability. In the hospital setting, this is typically mired in institutional bureaucracy and beyond the control of the individual supervising physician.
Any discussion of mid-level "independence" should be restricted to nurse practitioners.

agree for the most part although pa's do have their own state licenses to practice medicine. I trust you enough to send you mine by pm if you want to see it.
we work under our own license but can't do so without being affiliated with a physician. That physician would likely be named in a suit against a pa they sponsored as well as the group, hospital, the supplier of linens, the guy who sells hotdogs at the cart outside, etc
by solo I only meant no physician on site.
I'm guessing that a physician group that hired an "independent np" would also be named in a malpractice suit for the np's real or imagined malpractice act even if they never reviewed their charts.

 

[deleted87716]

by solo I only meant no physician on site.

Not the same as independent.

 

[deleted6669]

Not the same as independent.

that was the op's definition of independent(no physician on site) , not mine.

 

[deleted87716]

that was the op's definition of independent(no physician on site) , not mine.

The OP is a med student. You've never corrected a med student before...? 😉

 

[joeDO2]

The OP is a med student. You've never corrected a med student before...? 😉

hey now.... in my original post i used the term midlevels (referring to both NPs and PAs). Did not feel the need to separate them out. I do realize there is a difference regarding "complete" independence, however I suppose more appropriate terminology (although more long winded) would be "ability to practice without the direct supervision of an attending physician on site."

 

[deleted87716]

"Med student" is not a pejorative, even on this forum.

However, you do have much to learn, starting with the fact that all "midlevels" do not practice "independently."

True independence means no supervising physician anywhere.

 

[joeDO2]

"Med student" is not a pejorative, even on this forum.

However, you do have much to learn, starting with the fact that all "midlevels" do not practice "independently."

True independence means no supervising physician anywhere.

Of course I have much to learn.

There are some midlevels (NPs) in some states that do practice completely independently (as in new hampshire).

As I said before, I used the term independent as blanket statement over both PA and NP for the sake of brevity although admittedly, to be more clear, I should have separated NPs who work completely on their own (start a practice, hang a shingle) and PAs (who have a supervising physician but only have them review a few charts 30 days later).

In any event, my goal was just to see what your thoughts were on what the requirements should be for a midlevel (any) working without a physician on site.

 

[deleted87716]

I used the term independent as blanket statement over both PA and NP for the sake of brevity although admittedly, to be more clear, I should have separated NPs who work completely on their own

Brevity is the soul of wit, but clarity is always preferable. 😉

FWIW, most states with independent NP practice have absolutely no requirements for independent practice aside from licensure. New grad, experienced nurse...doesn't matter.

As far as PAs go, "supervision" is typically loosely defined. Experience is not a factor. Not legally, anyway.

 

[priorities2]

It's probably got to depend on the field as well, right? Psychiatric NPs can put out a shingle with no physician oversight in certain states and that seems to be just fine.

 

[jl lin]

I so weary of this topic, b/c it doesn't seem to be going away. My own current profession frustrates the hell out of me over this issue. What is the problem with NPs or midlevels functioning under the supervision of a physician for God's sake? Why are people so quick to want to remove systems of checks and balances? The nursing profession, at least to some degree, seems to take this position that total autonomy in practice, especially for primary care is the "only" way to go.

To which I ask, over and over again, WHY? If two heads are better than one, why in the world would you remove the one that has more overall education as well as more residency education??? The residency hours far outweigh what is required by midlevels. Pertinent clinical experience makes all the difference in the world.

I can not wait to be finished with my current track of education--current in nursing science--and I have been a critical care nurse for quite some time. I am sick of hearing this nonsense of NPs working without physician oversight. It's complete insanity to me. Yet, if I try to make an intelligent reflection on overall education and clinical residency experience, I get B***** slapped.

You know, as a critical care nurse, in many areas, at least in the adult world, I have had a fair amount of reasonable autonomy and influence. But I don't want to venture out of my scope of practice. It's not fair to the patients. I can give some perspective, cull data and what has been trending for the last 10 hours, etc, but I don't want to be left alone in this.

Example: I have worked in OH recovery units where fellows take call and cover problematic trends and emergencies. Great. And then I had the joy of working in a unit where you were pretty much left to pre-set orders, algorhithms, and then begging over the phone for the surgeon to please come back--b/c no one covered that particular open heart unit. It was fine when the newly recovering post-op pt was a clear-cut CABG with no major issues, comorbidities, complications. But when there was an issue--as often there are with many of the patients receiving OHS today--IT WAS UTTER HELL!
I remember begging a cardiology fellow from another unit to please come and examine the patient and data (who had been dumping 100's+ cc out of his CT nonstop.) Thank God I had worked with him at another (IMHO, better) hospital-OHS unit. So, God bless him, he came down, wrote appropriate orders--saved the patient's butt and mine. All the while the pt's CT surgeon on the phone said, "Hang more blood (7 units and FFP later), but don't overload the pt." What the? DDAVP was a joke on this pt, and the pt had some very serious comorbidities. Oh and the Nursing Supervisor was a sorry sight as well. I could write a book about this case.

It is so easy for things to go wrong, and it's easy to get in over your head. To this day, I refuse to work in an Open Heart Recovery Unit or any Unit that does not have appropriate physician coverage, period.

Yes, that's an extreme example, but this whole issue ticks me off to no end, and I am a nurse for God's sake. There is a reason that scopes of practice are established. And there is a reason that midlevel providers need to be covered by experienced physicians. If this ever changes, God help the patients and God help us all.

 

[GeneValgene]

I so weary of this topic, b/c it doesn't seem to be going away. My own current profession frustrates the hell out of me over this issue. What is the problem with NPs or midlevels functioning under the supervision of a physician for God's sake? Why are people so quick to want to remove systems of checks and balances? The nursing profession, at least to some degree, seems to take this position that total autonomy in practice, especially for primary care is the "only" way to go.

To which I ask, over and over again, WHY? If two heads are better than one, why in the world would you remove the one that has more overall education as well as more residency education??? The residency hours far outweigh what is required by midlevels. Pertinent clinical experience makes all the difference in the world.

I can not wait to be finished with my current track of education--current in nursing science--and I have been a critical care nurse for quite some time. I am sick of hearing this nonsense of NPs working without physician oversight. It's complete insanity to me. Yet, if I try to make an intelligent reflection on overall education and clinical residency experience, I get B***** slapped.

You know, as a critical care nurse, in many areas, at least in the adult world, I have had a fair amount of reasonable autonomy and influence. But I don't want to venture out of my scope of practice. It's not fair to the patients. I can give some perspective, cull data and what has been trending for the last 10 hours, etc, but I don't want to be left alone in this.

Example: I have worked in OH recovery units where fellows take call and cover problematic trends and emergencies. Great. And then I had the joy of working in a unit where you were pretty much left to pre-set orders, algorhithms, and then begging over the phone for the surgeon to please come back--b/c no one covered that particular open heart unit. It was fine when the newly recovering post-op pt was a clear-cut CABG with no major issues, comorbidities, complications. But when there was an issue--as often there are with many of the patients receiving OHS today--IT WAS UTTER HELL!
I remember begging a cardiology fellow from another unit to please come and examine the patient and data (who had been dumping 100's+ cc out of his CT nonstop.) Thank God I had worked with him at another (IMHO, better) hospital-OHS unit. So, God bless him, he came down, wrote appropriate orders--saved the patient's butt and mine. All the while the pt's CT surgeon on the phone said, "Hang more blood (7 units and FFP later), but don't overload the pt." What the? DDAVP was a joke on this pt, and the pt had some very serious comorbidities. Oh and the Nursing Supervisor was a sorry sight as well. I could write a book about this case.

It is so easy for things to go wrong, and it's easy to get in over your head. To this day, I refuse to work in an Open Heart Recovery Unit or any Unit that does not have appropriate physician coverage, period.

Yes, that's an extreme example, but this whole issue ticks me off to no end, and I am a nurse for God's sake. There is a reason that scopes of practice are established. And there is a reason that midlevel providers need to be covered by experienced physicians. If this ever changes, God help the patients and God help us all.

well said. i'm a midlevel by the way.

 

[AnnoyedByFreud]

I wonder how much of this is hyperbole. NPs have independent practice in multiple states and the world hasn't imploded yet. Most NPs who live in ind. practice states don't really practice independently. Even the ones I know who own their own private practices (or who are partners in a private practice) still collaborate and confer with other healthcare providers all the time. They just don't have to pay a physician to oversee them, so sometimes their salaries are higher. Sometimes they aren't. Some hospitals and clinics still require some sort of collaboration or supervision, despite the fact that the state doesn't. I dunno, I just really haven't noticed any issues with this, at least not where I used to live (an ind. practice state). People are dramatic.

There are a lot of states where NPs don't have independent practice, but the physician oversight is minimal, at most. I mean come on, retrospective chart review? Come on. How come people don't complain about the states where the physician oversight might still be the law, but it's pretty much in name only?

 

[SouthSideSteve]

Example: I have worked in OH recovery units where fellows take call and cover problematic trends and emergencies. Great. And then I had the joy of working in a unit where you were pretty much left to pre-set orders, algorhithms, and then begging over the phone for the surgeon to please come back--b/c no one covered that particular open heart unit. It was fine when the newly recovering post-op pt was a clear-cut CABG with no major issues, comorbidities, complications. But when there was an issue--as often there are with many of the patients receiving OHS today--IT WAS UTTER HELL!
I remember begging a cardiology fellow from another unit to please come and examine the patient and data (who had been dumping 100's+ cc out of his CT nonstop.) Thank God I had worked with him at another (IMHO, better) hospital-OHS unit. So, God bless him, he came down, wrote appropriate orders--saved the patient's butt and mine. All the while the pt's CT surgeon on the phone said, "Hang more blood (7 units and FFP later), but don't overload the pt." What the? DDAVP was a joke on this pt, and the pt had some very serious comorbidities. Oh and the Nursing Supervisor was a sorry sight as well. I could write a book about this case.

It is so easy for things to go wrong, and it's easy to get in over your head. To this day, I refuse to work in an Open Heart Recovery Unit or any Unit that does not have appropriate physician coverage, period.

Yes, that's an extreme example, but this whole issue ticks me off to no end, and I am a nurse for God's sake. There is a reason that scopes of practice are established. And there is a reason that midlevel providers need to be covered by experienced physicians. If this ever changes, God help the patients and God help us all.

Sorry to go OT, but you called a cards fellow to come manage an issue on a fresh heart?

Your example doesn't necessarily have anything to do with not having in house ICU coverage. I've handled sick patients and bleeders over the phone, but I've never called a medicine resident/fellow/attending to come manage a surgical issue. Thousands of CVICUs around the country work just fine with no in house coverage.

I don't feel so bad about getting OT, because I'm not even sure what that story has to do with midlevel independent practice anyway. You didn't like the orders you were getting and got some poor medicine fellow to write what you wanted.

 

[jl lin]

Sorry to go OT, but you called a cards fellow to come manage an issue on a fresh heart?

Your example doesn't necessarily have anything to do with not having in house ICU coverage. I've handled sick patients and bleeders over the phone, but I've never called a medicine resident/fellow/attending to come manage a surgical issue. Thousands of CVICUs around the country work just fine with no in house coverage.

I don't feel so bad about getting OT, because I'm not even sure what that story has to do with midlevel independent practice anyway. You didn't like the orders you were getting and got some poor medicine fellow to write what you wanted.

No, in the best centers OH recovery units are covered by CT surgical fellows with CT surgical residents, and/or critical anesthesiology. I called someone who had a. had the power of a reasonably relevant licence and experience and a good pen. That man was MORE than a mench. The patient was NOT just a bleeder. She was a highly unstable bleeder with multiple immune systems problems, the least of which shot the hell out of her kidneys before surgery, and she was going into ARDS. This very young lady was a trainwreck of trainwrecks.

I wasn't getting orders! That was the point, and the patient was swirling the bowl. Get it???? Its relevant because it assumes a level of practice that is beyond even the best critical care nurses. For one thing, I can't take the patient back into the OR. I can't put the patient on bypass, and I am not Jesus walking on the water.

Give me a break. The situation was unsafe and UNFAIR to both patients and nurses, and I contend to this day that the institution was foolish for not providing surgical, or at least critical care medicine coverage DIRECTLY for THOSE PATIENTS IN THAT UNIT. A phone call won't cut it if the patient is sick enough, and she was. And the phone calls that were made resulted in doing NADA for the patient. Yes. Fine. I'll just let her code and die. She was sicker than a number of patients I have had with open chests on IABP (or ECMO-as the case may be) and too many other pieces of machinary and gtts coming out everyone ears.

People don't realize how quickly things can start flooding once the tidal wave hits. Adult critical care people at times can be slower in realizing this. When you move into neonate and pediatric open heart and intensive care, the velocity with which the **** hits the fan literally leaves your head spinning and you peeing your pants. That's when you see how quickly--instantaneously--things can change for the worse--from what was one second before, a tranquil state. Kids often don't give you any lead time like adults can. And you learn not to take anything for granted--- unless you are just an arrogant, devil may care, narcissistic pony.

Here's the thing about the whole midlevel issue:

Loads, and I mean loads of intensive, full scale research needs to be done--objective, and unbiased. And even with that and that which is floating around already, NPs are not medically educated and prepared to be physicians, period. They aren't. People are kidding themselve on this. I have worked some excellent nurse practitioners--mostly they are the ones that worked for a long time in acute or critical care prior to going into their grad school programs. Their experience is what makes them top notch. But the whole process of becoming an NP or PA is NOT like it is to become a physician. Until it is, the whole argument is ridiculous.

 

[zenman]

I wonder how much of this is hyperbole. NPs have independent practice in multiple states and the world hasn't imploded yet. Most NPs who live in ind. practice states don't really practice independently. Even the ones I know who own their own private practices (or who are partners in a private practice) still collaborate and confer with other healthcare providers all the time. They just don't have to pay a physician to oversee them, so sometimes their salaries are higher. Sometimes they aren't. Some hospitals and clinics still require some sort of collaboration or supervision, despite the fact that the state doesn't. I dunno, I just really haven't noticed any issues with this, at least not where I used to live (an ind. practice state). People are dramatic.

There are a lot of states where NPs don't have independent practice, but the physician oversight is minimal, at most. I mean come on, retrospective chart review? Come on. How come people don't complain about the state's where the physician oversight might still be the law, but it's pretty much in name only?

I live in an independent practice state but the only way that would happen would be for me to be in private practice. I work in a hospital and I have a medical director. She also has a boss in administration (who has a say in how she practices). I do like having the ability to collaborate with others, even when for example, it's with a psychiatrist with over 40 years experience who replies, "I have no idea what to do next." My boss does like the fact that since I'm in an independent practice state, she doesn't have to cosign any of my documentation.

 

[AnnoyedByFreud]

Right. As far as I can tell, "independent practice" doesn't really change how must NP's practice. Nobody practices in a vacuum. It seems like it's mostly a paperwork issue, makes it slightly easier to have a private practice, possibly allows for more earning potential, etc.

 

[alpha2agonist]

we have a winner! Independent practice for 99.99999% of mid levels means asking when we do not know and why should we pay for the 99.9999% of the time we do.

 

[deleted87716]

we have a winner! Independent practice for 99.99999% of mid levels means asking when we do not know and why should we pay for the 99.9999% of the time we do.

So...you're a midlevel, as well as an attending (your user status)? Please explain. Or, correct.

 

[ChillyRN]

I'd agree with the comments that no one practices in a vacuum and all of us seek out peer support when we need it. I started as a new grad in an independent practice state. I have no "collaboration" or "supervision" and I didn't on my first day as a practicing NP. They said, go for it, and good luck.

My colleagues do not expect me to bother them, but are more than happy to help me out when I really do need an experienced provider to lend an opinion. There are a few things that I know a lot about and they ask me about those issues sometimes too. Most of the time we all do our own thing and only see each other at lunch, and then we just talk about the Olympics or our kids, lol. Most everybody comes to my place on Friday nights for drinks and a cookout and we do talk about some of the weird stuff we saw during the week and have an informal "peer review" poolside, but we are all half in the bag so I don't think it counts. We are friends, we are peers, and we help each other. We don't criticize one another or compete, (except at cards-which is vicious). 😉

I suppose it may be because they work in a state that has had independent NP practice for 20 years, but the physicians I work with are very supportive of independent NPs, and of me in particular. They know I am on a learning curve as a new grad and still don't expect to have to back me up that much, and I haven't let them down yet. I get a lot of positive feedback from them and feel supported enough to go get help when the situation fails my personal litmus test: "will the patient be harmed if I don't figure this out right now?" If I think the answer might be yes, I get help. If not, I work it out myself on my own time. Am I less efficient than a physician that had the advantage of a 3 years family practice residency? Probably. Am I less safe? No evidence of that to date.

I'm doing a good job, and I'm loving it. I'm on a learning curve for certain, and I'm going to get better at it. I am confident I will be an expert family practice provider one day because I have an excellent education, I am dedicated and I work hard. There are probably a lot of potential patients out there that don't want to see me because I am a NP and that's OK. My first day was last December, and as of July 30th I am no longer accepting new patients. My panel is full. That's my panel, of my own patients. I really love being a NP and I love my job and colleagues. 🙂

 

[fab4fan]

I so weary of this topic, b/c it doesn't seem to be going away. My own current profession frustrates the hell out of me over this issue. What is the problem with NPs or midlevels functioning under the supervision of a physician for God's sake? Why are people so quick to want to remove systems of checks and balances? The nursing profession, at least to some degree, seems to take this position that total autonomy in practice, especially for primary care is the "only" way to go.

To which I ask, over and over again, WHY? If two heads are better than one, why in the world would you remove the one that has more overall education as well as more residency education??? The residency hours far outweigh what is required by midlevels. Pertinent clinical experience makes all the difference in the world.

I can not wait to be finished with my current track of education--current in nursing science--and I have been a critical care nurse for quite some time. I am sick of hearing this nonsense of NPs working without physician oversight. It's complete insanity to me. Yet, if I try to make an intelligent reflection on overall education and clinical residency experience, I get B***** slapped.

You know, as a critical care nurse, in many areas, at least in the adult world, I have had a fair amount of reasonable autonomy and influence. But I don't want to venture out of my scope of practice. It's not fair to the patients. I can give some perspective, cull data and what has been trending for the last 10 hours, etc, but I don't want to be left alone in this.

Example: I have worked in OH recovery units where fellows take call and cover problematic trends and emergencies. Great. And then I had the joy of working in a unit where you were pretty much left to pre-set orders, algorhithms, and then begging over the phone for the surgeon to please come back--b/c no one covered that particular open heart unit. It was fine when the newly recovering post-op pt was a clear-cut CABG with no major issues, comorbidities, complications. But when there was an issue--as often there are with many of the patients receiving OHS today--IT WAS UTTER HELL!
I remember begging a cardiology fellow from another unit to please come and examine the patient and data (who had been dumping 100's+ cc out of his CT nonstop.) Thank God I had worked with him at another (IMHO, better) hospital-OHS unit. So, God bless him, he came down, wrote appropriate orders--saved the patient's butt and mine. All the while the pt's CT surgeon on the phone said, "Hang more blood (7 units and FFP later), but don't overload the pt." What the? DDAVP was a joke on this pt, and the pt had some very serious comorbidities. Oh and the Nursing Supervisor was a sorry sight as well. I could write a book about this case.

It is so easy for things to go wrong, and it's easy to get in over your head. To this day, I refuse to work in an Open Heart Recovery Unit or any Unit that does not have appropriate physician coverage, period.

Yes, that's an extreme example, but this whole issue ticks me off to no end, and I am a nurse for God's sake. There is a reason that scopes of practice are established. And there is a reason that midlevel providers need to be covered by experienced physicians. If this ever changes, God help the patients and God help us all.

👍 + 100 gajillion