Midlevel practitioners/pain mngmt

[hope2bnmd!]

Hello all, was wondering what your opinions were on midlevel practitioners impinging on the practice of pain management. i am going in to anesthesia, and as we all know, CRNA's continue to impinge. Is pain a field which is sort of insulated from this impingment?

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[Stimulate]

PA-Cs and NPs are working in the field of pain management but by definition they work under the supervision of or in collaboration with pain management physicians. To my knowledge there are no independently practicing interventional pain management NPs or PA-Cs. They simply do not have the procedure training or scope of practice rights.

The CRNAs are trying to expand their scope of practice illegitimately by seeking "advisory opinions" from state boards of nursing, most recently in Louisiana (read the bloated CRNA salary post for some details on that). Their efforts were shot down by the Louisiana supreme court but I am sure the battle isn't over.

This issue is not unique to CRNAs, other specialties are trying to bypass the legitimate pathways to expand scope of practice as well (podiatrists, optometrists, etc.). When their respective boards issue an "advisory opinion" saying that say "podiatrists are authorized to do knee replacements" (just as an example) then the medical community (orthopedists, AMA, etc) have to seek an injuction against them and proceed with an expensive litigation battle to halt this expanded scope of practice. You can read more about the defense of these issues on the AMA website because they are involved in this across a wide variety of specialties.

Unfortunately due to shrinking reimbursements in healthcare and pure greed, everybody is trying to expand their services (at the expense of quality to patients) to supplement their incomes. They focus on whether we (physicians) can prove that they are causing "harm" rather than using common sense to evaluate the quality of training. They ask patients to sacrifice quality of care to improve their access to care. There is a huge shortage of neurosurgeons but we don't see their quality of training declining, nor do we see Neurosurgery Assistants practicing independently.

Why anyone would accept this in anesthesiology or pain management is beyond my understanding, but it all comes down to the great motivator...money. Insurers and Medicare all want to cut spending and by destroying a medical specialty and renaming it a nursing specialty they can cut payments tremendously.

As a friend of mine says, "Everybody wants to be captain of the ship without going to captain's school."

 

[FirstAid]

Just out of curiousity, how "interventional" are these PA-C, NP, and CRNAs in the practice of pain? I have a hard time picturing these mid-level providers performing spinal cord stims, intrathecal pumps, vertebroplasty/kyphoplasty, discography, IDET, etc, even under the supervision of a pain physician. They may be able to do epidural injections under the guidance of a pain physician, but it seems to me that it would be very difficult for them to perform what I would consider the more "surgical" procedures of pain management. To me, that would be like letting an NP or PA do a lap chole under the guidance of a general surgeon. So, am I correct in thinking that it will be very difficult for mid-levels to actually enter and "fully practice" interventional pain? And I admit that this is all under the assumption that most pain physicians will hopefully not choose to train mid-levels in these more advanced interventional techniques (which I acknowledge that a few are out there). Any input or opinions are appreciated.

Future anesthesia intern and pain specialist hopeful

 

[Stimulate]

Our pain NPs and PA-Cs primary see office visits (typically medication refills) and a smattering of new consults when we are busy. They also assist with rounding on the inpatients (both chronic and acute pain patients). They are a welcome and essential component of our care team. None of them assist with or perform interventional pain procedures.

In the private practice setting I am aware of a few practices who utilize their PA-Cs in the operating room (helping position and prep the patient, sometimes even closing the implantable generator pockets) but none of them are performing the key portions of the procedure.

Greed is a pervasive entity however, and if some academic pain practices wish to increase their revenue I can see the potential for training midlevels in the future. I hope that this is not the case, and part of the key to preventing this is maintaining reimbursement at physician levels. For example, if cuts to procedures become too severe some practices may start to gradually expand the scope of practice of their midlevel providers to increase their volume. I don't see this happening anytime soon but we do need to make sure that today's short-term gain doesn't destroy the specialty's future.

 

[Mister Mxyzptlk]

Our pain NPs and PA-Cs primary see office visits (typically medication refills) and a smattering of new consults when we are busy. They also assist with rounding on the inpatients (both chronic and acute pain patients). They are a welcome and essential component of our care team. None of them assist with or perform interventional pain procedures.

Just to demonstrate the diversity in practice, I use an RN for

1. Med refill visits.
2. Pump refills and reprogramming (only with a physician's order).
3. Triages the the clinical calls during the day.
4. In the procedure room she is the preop nurse, anesthetist, circulator, xray tech, and PACU nurse.

I'm trying to teach her to move the table around under my needle so all I have to do is stand there and activate the foot pedal.

I can't think of a better job for an RN that wants to use all of their skills.

 

[Stimulate]

I'm trying to teach her to move the table around under my needle so all I have to do is stand there and activate the foot pedal.

I can't think of a better job for an RN that wants to use all of their skills.

I guess this is OK as long as there are separate doctor's orders for each motion of the foot pedal.

 

[Tenesma]

i have been thinking of hiring an RN to be a mini-me for office visits

1) intake (chief complaint, med updates, allergies, changes in medical stuff going on), brief cursory exam, getting all the imaging pulled up on either the viewing box and/or computer screen

2) i come in, say hi, do a quick exam and tell the patient what my dx and treatment is and then shake hands and leave, while the RN either does the RX / explains the recommended procedure, etc...

3) i then dictate my part (exam, dx and treatment plan) and the RN dictates all the rest to have the highest-coding visit possible...

does anybody do a variation on this - i feel this will allow me to see more patients per day and get home at reasonable times???