Midlevel problem...what would you do?

[wareagle726]

Okay so I'm sure this will devolve into the usual Jenny talk. Before it does I want to at least get some serious answers. Here's the situation from the last 2 nights. I work I a very high volume/high acuity place. 2 docs at night, one NP that leaves after a little after midnight. Docs usually 25-30/night. Intubate every night, multiple lines/chest tubes/lacs, etc... We depend on the MLPs to see the lvl4 and 5 stuff. Newer MLP isn't seeing those beyond 8p.

We told this person we needed help and please see the ones waiting and were told "I can't handle any more patients, I'm stretched as far as I can be." I was initially irritated and my colleague made the point that she'd rather see them and give good care than make someone be in the weeds and us have to sign off on poor care. It made me think.

Honestly I'm kinda like "I'm stretched beyond thin every night" but at the same time I don't want to look at that chart where this person sent home an obvious bad pathology that was missed and is now my legal problem.

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[GonnaBeADoc2222]

Okay so I'm sure this will devolve into the usual Jenny talk. Before it does I want to at least get some serious answers. Here's the situation from the last 2 nights. I work I a very high volume/high acuity place. 2 docs at night, one NP that leaves after a little after midnight. Docs usually 25-30/night. Intubate every night, multiple lines/chest tubes/lacs, etc... We depend on the MLPs to see the lvl4 and 5 stuff. Newer MLP isn't seeing those beyond 8p.

We told this person we needed help and please see the ones waiting and were told "I can't handle any more patients, I'm stretched as far as I can be." I was initially irritated and my colleague made the point that she'd rather see them and give good care than make someone be in the weeds and us have to sign off on poor care. It made me think.

Honestly I'm kinda like "I'm stretched beyond thin every night" but at the same time I don't want to look at that chart where this person sent home an obvious bad pathology that was missed and is now my legal problem.

Their shift goes till 12a and they stop seeing patients at 8p?

Are you SDG? CMG? Hospital employee?

If SDG, warn them, and then fire them if no corrective action taken.

If CMG / hospital employed youre prob screwed. Try talking to director. We have midlevels who see 1 pph of extremely low acuity and nothing ever happens.

 

[gruemd]

So this person isn't seeing new (easier) patients for 4 hours before their shift is over? If they refuse I'd just go to the medical director. Sounds like they suck enough at the job that they either need to learn how to suck less, or work elsewhere. Currently this just gives license for this person to presumably be paid their regular hourly rate while just winding down their shift very, very early.

 

[BoardingDoc]

Okay so I'm sure this will devolve into the usual Jenny talk. Before it does I want to at least get some serious answers. Here's the situation from the last 2 nights. I work I a very high volume/high acuity place. 2 docs at night, one NP that leaves after a little after midnight. Docs usually 25-30/night. Intubate every night, multiple lines/chest tubes/lacs, etc... We depend on the MLPs to see the lvl4 and 5 stuff. Newer MLP isn't seeing those beyond 8p.

We told this person we needed help and please see the ones waiting and were told "I can't handle any more patients, I'm stretched as far as I can be." I was initially irritated and my colleague made the point that she'd rather see them and give good care than make someone be in the weeds and us have to sign off on poor care. It made me think.

Honestly I'm kinda like "I'm stretched beyond thin every night" but at the same time I don't want to look at that chart where this person sent home an obvious bad pathology that was missed and is now my legal problem.

If you control staffing: reiterate expectations. If they continue to behave this way, fire them. If you do not control staffing: reiterate that they are working until midnight and everyone is working hard and they are expected to pull their weight like everyone else. If they continue to behave that way, email whoever control staffing and explain in no uncertain terms that this person is refusing to see new patients in the last 4 hours of their shift.

 

[miacomet]

Yeah, if your group controls them, fire them and replace with a doc or a better mid-level.

If you don't, email the staffing person and explain this is a patient safety issue. They won't care, because mid levels are considered gods by admin, but at least you can try.

Also, this is why EM sucks as a field and why we should all flee. If this job isn't paying $300 an hour plus, there are easier jobs for you out there.

 

[Groove]

Okay so I'm sure this will devolve into the usual Jenny talk. Before it does I want to at least get some serious answers. Here's the situation from the last 2 nights. I work I a very high volume/high acuity place. 2 docs at night, one NP that leaves after a little after midnight. Docs usually 25-30/night. Intubate every night, multiple lines/chest tubes/lacs, etc... We depend on the MLPs to see the lvl4 and 5 stuff. Newer MLP isn't seeing those beyond 8p.

We told this person we needed help and please see the ones waiting and were told "I can't handle any more patients, I'm stretched as far as I can be." I was initially irritated and my colleague made the point that she'd rather see them and give good care than make someone be in the weeds and us have to sign off on poor care. It made me think.

Honestly I'm kinda like "I'm stretched beyond thin every night" but at the same time I don't want to look at that chart where this person sent home an obvious bad pathology that was missed and is now my legal problem.

Honestly, that sounds more like a job problem than an APC problem. Your job sounds miserable. 25-30 EACH NIGHT on average?! With multiple procedures and what sounds like a flaming turd pile of high acuity? Yuck. I hope you're taking a baby aspirin each day. I'd find a new job before I'd find a new APC.

 

[miacomet]

Honestly, that sounds more like a job problem than an APC problem. Your job sounds miserable. 25-30 EACH NIGHT on average?! With multiple procedures and what sounds like a flaming turd pile of high acuity? Yuck. I hope you're taking a baby aspirin each day. I'd find a new job before I'd find a new APC.

This. I'm changing my previous salary requirement. This should be a $500 an hour job.

 

[Groove]

This. I'm changing my previous salary requirement. This should be a $500 an hour job.

At least. It reminds me of a local site our CMG has nearby where they can't staff it appropriately and keep trying to get me to work shifts there. It's insane acuity and they are supposed to have 2 docs overnight at a minimum with APC and they can't/won't staff it appropriately so several nights of the week it will be a single doc covering the entire ED. We're talking 40 something rooms with nothing but a single doc from midnight/early a.m. to morning. I checked the board 2 nights recently and the doc had over 40 patients in the dept waiting to be seen. Only a third of those were WR patients. The bonuses my CMG offers to cover those shifts can be over 2K each but at some point you have to ask yourself....Is this even worth it? It's like playing Russian roulette with a malpractice revolver. So far, I've refused to work shifts when it's understaffed like that. It's just not worth it to me.

Leadership keeps complaining that they can't keep docs at this particular site because they all keep quitting and I keep thinking "Well no @hit!" Hell, I'd quit after a shift like that. So far, the only docs they can hire to staff it are brand new baby graduates who have no idea that kind of environment isn't the norm.

 

[miacomet]

At least. It reminds me of a local site our CMG has nearby where they can't staff it appropriately and keep trying to get me to work shifts there. It's insane acuity and they are supposed to have 2 docs overnight at a minimum with APC and they can't/won't staff it appropriately so several nights of the week it will be a single doc covering the entire ED. We're talking 40 something rooms with nothing but a single doc from midnight/early a.m. to morning. I checked the board 2 nights recently and the doc had over 40 patients in the dept waiting to be seen. Only a third of those were WR patients. The bonuses my CMG offers to cover those shifts can be over 2K each but at some point you have to ask yourself....Is this even worth it? It's like playing Russian roulette with a malpractice revolver. So far, I've refused to work shifts when it's understaffed like that. It's just not worth it to me.

Leadership keeps complaining that they can't keep docs at this particular site because they all keep quitting and I keep thinking "Well no @hit!" Hell, I'd quit after a shift like that. So far, the only docs they can hire to staff it are brand new baby graduates who have no idea that kind of environment isn't the norm.

Maybe they can hire a midlevel to do it all

 

[doggydog]

Maybe they can hire a midlevel to do it all

Do you think constantly being on this website makes your hate EM more or less?

 

[miacomet]

Do you think constantly being on this website makes your hate EM more or less?

yes

 

[Brigade4Radiant]

OP your job sounds awful so you are seeing 25-30 patients an hour with acuity? You better be making At least 300 an hour. Also many places wont care about the NP if overall they see a lot. It seems like you probably need someone to come in at 9pm. As long as the NP sees a certain amount of patients a lot of CMGs wont care

Firing an NP/PA doesn't really hold much weight anymore since they have so many options they will have a job in your hospital seeing cards patients or working in the ICU with the ER experience. Even the Medical Director doesn't have as much power to fire midlevels unless the regional manager approves for a good reason.

Good NP and PAs are hard to come by since they have far more options than Doctors. The NP can work in urgent care making the same or the office.

 

[namethatsmell]

Op, are you required to co-sign midlevel notes? If so, and you don’t a) control staffing/hiring/firing and b) aren’t being paid at least 350/hr+benes or $400 IC—you need a job change.

 

[Mount Asclepius]

Wow that seems crazy to me. I work in a double coverage place. We routinely intubate multiple people every night and I would say have a minimum of 6 ICU admits between med and trauma. Not academic either. It's a grind but it's fun. usually see around 22-25 in 11 hour shift. We have great support staff which is what makes it possible.

Okay so I'm sure this will devolve into the usual Jenny talk. Before it does I want to at least get some serious answers. Here's the situation from the last 2 nights. I work I a very high volume/high acuity place. 2 docs at night, one NP that leaves after a little after midnight. Docs usually 25-30/night. Intubate every night, multiple lines/chest tubes/lacs, etc... We depend on the MLPs to see the lvl4 and 5 stuff. Newer MLP isn't seeing those beyond 8p.

We told this person we needed help and please see the ones waiting and were told "I can't handle any more patients, I'm stretched as far as I can be." I was initially irritated and my colleague made the point that she'd rather see them and give good care than make someone be in the weeds and us have to sign off on poor care. It made me think.

Honestly I'm kinda like "I'm stretched beyond thin every night" but at the same time I don't want to look at that chart where this person sent home an obvious bad pathology that was missed and is now my legal problem.

I’m suspicious you might be inflating your situation like before.

Either way, agree with @BoardingDoc’s recommendation.

This job deserves much more than $300+/hr, not just $300/hr. I do better than that at my SDG and don’t average as many pph.

 

[RustedFox]

No new patients after 8pm?!

Even my CMG shop would show that Jenny the door. We had to do just that earlier this year.

 

[Brigade4Radiant]

It depends what they are doing. If they meet the minimum threshold and if they are charting a lot of CMGs will allow them to get away without seeing new patients.


Doctors don’t have this luxury there is now a national push for these CMGs to hire new NPs to work in the ER since it’s gotten harder to recruit them

 

[emergentmd]

Your problem is not the MLP. Actually he/she is the least of your problems.

That's like fretting over the a $100 steak when you just bought a 100K boat.

 

[Rekt]

Their shift goes till 12a and they stop seeing patients at 8p?

Are you SDG? CMG? Hospital employee?

If SDG, warn them, and then fire them if no corrective action taken.

If CMG / hospital employed youre prob screwed. Try talking to director. We have midlevels who see 1 pph of extremely low acuity and nothing ever happens.

Agree with this. Just fire them if you’re an SDG. Not even worth talking to them.

Hospital employed? Absolutely good luck. 90% of our mid levels see less than any of the docs. Barely 1pph or less and stop 3hrs before end of shift. Despite complaints they’re here still making six figures barely doing any work.

 

[wareagle726]

I’m suspicious you might be inflating your situation like before.

Either way, agree with @BoardingDoc’s recommendation.

This job deserves much more than $300+/hr, not just $300/hr. I do better than that at my SDG and don’t average as many pph.

I don't really know why you think I'm inflating it but that's cool and all. We are a level 2 trauma facility. We have great support staff as previously stated. There is NO pushback from any admitting/consulting service which makes it doable. The job is really high acuity. We don't have a residency program. I don't know why this is hard to believe. Our numbers have gone up to 25+/night recently since they cut some hours out but the change is more level 4/5 stuff.

And we make around $275/hr.

Glad your job is easy and you get paid more.

All I wanted was some insight into how to handle that situation. Seems like since its CMG I really have no action to take.

 

[miacomet]

I don't really know why you think I'm inflating it but that's cool and all. We are a level 2 trauma facility. We have great support staff as previously stated. There is NO pushback from any admitting/consulting service which makes it doable. The job is really high acuity. We don't have a residency program. I don't know why this is hard to believe. Our numbers have gone up to 25+/night recently since they cut some hours out but the change is more level 4/5 stuff.

And we make around $275/hr.

Glad your job is easy and you get paid more.

All I wanted was some insight into how to handle that situation. Seems like since its CMG I really have no action to take.

It's not going to get better.
You are worth more as a human and a doctor than this, both in stress and in money.
Start working on your exit strategy.

 

[WorkNoteEmergency]

First step is look at the metrics for this person (PPH, RVU, avg ESI) and see how they stack up against the rest of the group. If they are about the same it will be more of a challenge to effect some change. If the metrics are the same, then it might be a case of this person front loading heavily during the shift but based on your description, I doubt that's the case. Once you can prove well below average metrics then you'll likely have to institute some form of remedial program to get this person up to speed at which point, if not successful, then you can talk about firing. You're looking at a minimum 4-6 month process.

There is probably some verbiage in your contract about working with and supervising MLP's, so you will have to establish some foundation before you and your partners start making noise about refusing to sign this person's charts, etc. It took not quite a year to get rid of a clearly incompetent NP in my hospital employed group.

 

[RustedFox]

I don't really know why you think I'm inflating it but that's cool and all. We are a level 2 trauma facility. We have great support staff as previously stated. There is NO pushback from any admitting/consulting service which makes it doable. The job is really high acuity. We don't have a residency program. I don't know why this is hard to believe. Our numbers have gone up to 25+/night recently since they cut some hours out but the change is more level 4/5 stuff.

And we make around $275/hr.

Glad your job is easy and you get paid more.

All I wanted was some insight into how to handle that situation. Seems like since its CMG I really have no action to take.

I used to see 26-32 with regularity at nights at my shop. Our volume is way down because "summer".

 

[Mount Asclepius]

I don't really know why you think I'm inflating it but that's cool and all. We are a level 2 trauma facility. We have great support staff as previously stated. There is NO pushback from any admitting/consulting service which makes it doable. The job is really high acuity. We don't have a residency program. I don't know why this is hard to believe. Our numbers have gone up to 25+/night recently since they cut some hours out but the change is more level 4/5 stuff.

And we make around $275/hr.

Glad your job is easy and you get paid more.

All I wanted was some insight into how to handle that situation. Seems like since it’s CMG I really have no action to take.

The pph numbers are certainly possible, but if that’s the case you are underpaid seeing 2.2-2.7 pph (25-30 per 11 hour shift) for $275/hour even if you are seeing more low acuity patients recently.

I’m just suspicious of your reported procedure numbers. You first claimed you intubate multiple people every shift and then still claim intubate every shift. Also multiple lines and chest tubes every shift? I work at a fairly high acuity center as well. I keep track of my procedure numbers. Over the past few years I intubate on average twice per month and place about 1 central line per month. Only a handful of chest tubes each year. Even my numbers are higher than average. Your numbers don’t mesh with nationally reported average procedure numbers even if at a high acuity center.

By the Numbers: Emergency Department Procedure Rates - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.

www.acepnow.com

We had a doc once who developed a bad reputation for intubating anyone who just looked at them wrong. Don’t be that person. BiPAP works. Or, don’t inflate your numbers.

Regardless I empathize with your midlevel situation. Not having control over staffing is painful.

 

[GatorCHOMPions]

It’s not all roses in SDG land, really depends on the exact setup. Where I work per diem this particular SDG has a few super partners, several “partners” who get a bonus of some kind but no actual say in operations, and several lemmings working 5 years of big time sweat equity. MLPs see 4s and 5s, occasional 3s, and tend to top out at 1 pph. I’m told it has been brought it up before but it’s been status quo for a while. A few of the partners/super partners are known to see less than 1.5 pph routinely. They are probably making huge coin off of the sweat equity guys and don’t care. The night shift gets absolutely crushed over and over again, usually about 2.5+ pph. Thankfully I never work nights.

 

[Brigade4Radiant]

I don't really know why you think I'm inflating it but that's cool and all. We are a level 2 trauma facility. We have great support staff as previously stated. There is NO pushback from any admitting/consulting service which makes it doable. The job is really high acuity. We don't have a residency program. I don't know why this is hard to believe. Our numbers have gone up to 25+/night recently since they cut some hours out but the change is more level 4/5 stuff.

And we make around $275/hr.

Glad your job is easy and you get paid more.

All I wanted was some insight into how to handle that situation. Seems like since its CMG I really have no action to take.

275 is the norm for 2 patients an hour with a decent pay or mix if you don’t work for a predatory CMG

I would say u hope you are getting rvu

I now rarely put in central lines unless I can’t get access or have bad access. You can run pressors peripherally

Also the ICU can do it if they need to. If I’m placing a central line I make sure pressors are running peripherally

 

[Mount Asclepius]

It’s not all roses in SDG land, really depends on the exact setup. Where I work per diem this particular SDG has a few super partners, several “partners” who get a bonus of some kind but no actual say in operations, and several lemmings working 5 years of big time sweat equity. MLPs see 4s and 5s, occasional 3s, and tend to top out at 1 pph. I’m told it has been brought it up before but it’s been status quo for a while. A few of the partners/super partners are known to see less than 1.5 pph routinely. They are probably making huge coin off of the sweat equity guys and don’t care. The night shift gets absolutely crushed over and over again, usually about 2.5+ pph. Thankfully I never work nights.

Agree that it depends on the setup. A SDG by definition is democratic. When people speak ill of SDGs they usually aren’t even discussing a SDG at all and are actually referring to malignant ownership groups. Our mature SDG group’s partners are all equal partners and make up the vast majority of the group with only a few pre-partners and part time employed physicians.

Our few MLPs only average around 1 pph and we are actively discussing their best utilization given the billing changes coming to EM MLP supervision in January 2024.

 

[Mount Asclepius]

275 is the norm for 2 patients an hour with a decent pay or mix if you don’t work for a predatory CMG

Fair pay as a norm is $150/patient for 2 pph and $300/hr. Some certainly make more depending upon payer mix. This is probably more common in SDGs with CMGs taking a variable cut from that depending upon the CMG. Disclaimer being I don’t have personal experience in the CMG world.

 

[miacomet]

The pph numbers are certainly possible, but if that’s the case you are underpaid seeing 2.2-2.7 pph (25-30 per 11 hour shift) for $275/hour even if you are seeing more low acuity patients recently.

I’m just suspicious of your reported procedure numbers. You first claimed you intubate multiple people every shift and then still claim intubate every shift. Also multiple lines and chest tubes every shift? I work at a fairly high acuity center as well. I keep track of my procedure numbers. Over the past few years I intubate on average twice per month and place about 1 central line per month. Only a handful of chest tubes each year. Even my numbers are higher than average. Your numbers don’t mesh with nationally reported average procedure numbers even if at a high acuity center.

By the Numbers: Emergency Department Procedure Rates - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.

www.acepnow.com

We had a doc once who developed a bad reputation for intubating anyone who just looked at them wrong. Don’t be that person. BiPAP works. Or, don’t inflate your numbers.

Regardless I empathize with your midlevel situation. Not having control over staffing is painful.

275 is the norm for 2 patients an hour with a decent pay or mix if you don’t work for a predatory CMG

I would say u hope you are getting rvu

I now rarely put in central lines unless I can’t get access or have bad access. You can run pressors peripherally

Also the ICU can do it if they need to. If I’m placing a central line I make sure pressors are running peripherally

Sadly a lot of shops pay less than that, even though they shouldn't, but people take these jobs. Some are hobbyists at the end of their careers, some who knows?

Agreed on the central lines. They can put them in in the unit, who wastes their time on this unless there is absolutely no access?

 

[RustedFox]

Sadly a lot of shops pay less than that, even though they shouldn't, but people take these jobs. Some are hobbyists at the end of their careers, some who knows?

Agreed on the central lines. They can put them in in the unit, who wastes their time on this unless there is absolutely no access?

Don't give away my favorite procedure to the unit.

All the ports. For all the meds.

 

[Mount Asclepius]

I like lines a lot too and readily do them when needed. If they are necessary then I don’t leave them to the ICU to do.

Agree though completely that peripheral pressors are fine the vast majority of the time. Has dramatically reduced the amount of lines I place.

They do take some time to do even if not much. Financially it makes more sense to see another patient or reduce a fracture over placing a line. Especially if your MLP is quitting early and you have a lot of patients to see.

 

[wareagle726]

The pph numbers are certainly possible, but if that’s the case you are underpaid seeing 2.2-2.7 pph (25-30 per 11 hour shift) for $275/hour even if you are seeing more low acuity patients recently.

I’m just suspicious of your reported procedure numbers. You first claimed you intubate multiple people every shift and then still claim intubate every shift. Also multiple lines and chest tubes every shift? I work at a fairly high acuity center as well. I keep track of my procedure numbers. Over the past few years I intubate on average twice per month and place about 1 central line per month. Only a handful of chest tubes each year. Even my numbers are higher than average. Your numbers don’t mesh with nationally reported average procedure numbers even if at a high acuity center.

By the Numbers: Emergency Department Procedure Rates - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.

www.acepnow.com

We had a doc once who developed a bad reputation for intubating anyone who just looked at them wrong. Don’t be that person. BiPAP works. Or, don’t inflate your numbers.

Regardless I empathize with your midlevel situation. Not having control over staffing is painful.

I totally get the suspicion. I didn't think it would be that much when I started there.

Either way, I think we got this one person's issue resolved. Or at least addressed. The same thing had happened with multiple other docs this week and one of my colleagues had already talked to the head MLP about it yesterday.

I like doing the procedures. When I'm doing a line the nurses appreciate it. I'm sure I do some unnecessary lines but I'd rather do them upfront and take it out than be scrambling later. Also, doing a procedure in general gives me a reprieve from the unending onslaught of "sign this please" even if only for a few minutes.

 

[Rendar5]

I also work at a very high acuity 40% admission rate level I trauma. 18-30 patients per night shift. I put in a central line once every few months and a chest tube with same frequency and intubate maybe once every 2-3 shifts. Procedures are time drains. Peripheral pressors, peripheral IJ’s (1 minute procedure compared with 5-10 minutes if they’re a difficult stick and trauma nurses can’t get access. Intubation is the only procedure I like.l cause it’s quick and I can dump them on icu right away

 

[miacomet]

I also work at a very high acuity 40% admission rate level I trauma. 18-30 patients per night shift. I put in a central line once every few months and a chest tube with same frequency and intubate maybe once every 2-3 shifts. Procedures are time drains. Peripheral pressors, peripheral IJ’s (1 minute procedure compared with 5-10 minutes if they’re a difficult stick and trauma nurses can’t get access. Intubation is the only procedure I like.l cause it’s quick and I can dump them on icu right away

Agreed, unless you *have* to do them to dispo/save the patient- lac repairs, reductions, intubations, chest tubes.

 

[Siggy]

275 is the norm for 2 patients an hour with a decent pay or mix if you don’t work for a predatory CMG

I would say u hope you are getting rvu

I now rarely put in central lines unless I can’t get access or have bad access. You can run pressors peripherally

Also the ICU can do it if they need to. If I’m placing a central line I make sure pressors are running peripherally

You can run pressors peripherally... but the evidence supports this with 20 gauge or higher in the AC or higher and the nurse checking every hour.

The 22 gauge in the hand that I get often under the guise of "but but but peripheral pressors" is not evidence based as safe.

Also if your PLP is seeing 1 PPH, train them to do the monkey skills like CVC placement. I'd rather have that then having the ED PLP trying to admit a burn patient to the ICU who has 2 separate indications for transfer to a burn center, but never presented the patient to the burn center.

 

[thegenius]

Okay so I'm sure this will devolve into the usual Jenny talk. Before it does I want to at least get some serious answers. Here's the situation from the last 2 nights. I work I a very high volume/high acuity place. 2 docs at night, one NP that leaves after a little after midnight. Docs usually 25-30/night. Intubate every night, multiple lines/chest tubes/lacs, etc... We depend on the MLPs to see the lvl4 and 5 stuff. Newer MLP isn't seeing those beyond 8p.

We told this person we needed help and please see the ones waiting and were told "I can't handle any more patients, I'm stretched as far as I can be." I was initially irritated and my colleague made the point that she'd rather see them and give good care than make someone be in the weeds and us have to sign off on poor care. It made me think.

Honestly I'm kinda like "I'm stretched beyond thin every night" but at the same time I don't want to look at that chart where this person sent home an obvious bad pathology that was missed and is now my legal problem.

I would replace that newer MLP if possible. Or never schedule them at night. There are only so many things you can do. At the end of the day patients will be waiting a lot longer and then they complain. If patients complain go to mgmt and say "I can't see any more people, and the newer MLP isn't seeing that many." Leave it in their hands. You're kind of SOL if there is a bad outcome, since you and your colleague are off putting in lines, tubes, and foleys in

I'm not sure how easy it is to fire an MLP. Depends on their contract, etc. We have a lazy NP and we don't know what to do with her. Been with us for about 1 year now.

 

[thegenius]

All I wanted was some insight into how to handle that situation. Seems like since its CMG I really have no action to take.

If you are so inclined, I would get some data to back your claims. Like average wait time is 2x when that MLP is around, the MLP sees x/hr or x/shift while all the other MLPs are doing more. when you tell your CMG about it...request that that MLP not work night shifts.
If you tell your CMG enough times they might change the schedule or fire them. At the end of the day MLPs are resources too and if they just make $60/hr seeing 5 patients total on a shift, then they are not worth it. They have to earn their keep too.

 

[BoardingDoc]

when you tell your CMG about it...request that that MLP not work night shifts.

I don't know that rewarding bad behavior is the direction that I'd go with this one.

 

[RustedFox]

I would replace that newer MLP if possible. Or never schedule them at night. There are only so many things you can do. At the end of the day patients will be waiting a lot longer and then they complain. If patients complain go to mgmt and say "I can't see any more people, and the newer MLP isn't seeing that many." Leave it in their hands. You're kind of SOL if there is a bad outcome, since you and your colleague are off putting in lines, tubes, and foleys in

I'm not sure how easy it is to fire an MLP. Depends on their contract, etc. We have a lazy NP and we don't know what to do with her. Been with us for about 1 year now.

We had some that were so bad at LastJobSite. So B.A.D.

And nope; couldn't get rid of them.

 

[Fox800]

Agree with this. Just fire them if you’re an SDG. Not even worth talking to them.

Hospital employed? Absolutely good luck. 90% of our mid levels see less than any of the docs. Barely 1pph or less and stop 3hrs before end of shift. Despite complaints they’re here still making six figures barely doing any work.

I would be happy to see 5 patients in an 8 hour shift and make six figures. Sounds pretty cake and you do some telemedicine or day trading while at work! Sign me up.

 

[thegenius]

I don't know that rewarding bad behavior is the direction that I'd go with this one.

Yo well sometimes we have no good choices. If firing a lazy MLP can't be done, then move them to when it's less busy.

Practically speaking, first start collecting data on how many they see compared to other MLPs. Then ask them to pick it up. If no change move them to less busy shifts. If that doesn't work then fire them, or talk to legal about terminating their position. In real life what else can be done?

 

[Arcan57]

Yo well sometimes we have no good choices. If firing a lazy MLP can't be done, then move them to when it's less busy.

Practically speaking, first start collecting data on how many they see compared to other MLPs. Then ask them to pick it up. If no change move them to less busy shifts. If that doesn't work then fire them, or talk to legal about terminating their position. In real life what else can be done?

Start leaving open browser windows with FAQs on starting up your own botox clinic and hope they get the hint? Try to hook them up with a specialist that's making extra money running an MLP staffed IM/FM clinic? Start up a relationship with your most unstable charge RN and get them to start spreading viscious rumors about the MLP? File an anonymous complaint with HR regarding sexual misconduct with a patient or drug diversion?

 

[thegenius]

Start leaving open browser windows with FAQs on starting up your own botox clinic and hope they get the hint? Try to hook them up with a specialist that's making extra money running an MLP staffed IM/FM clinic? Start up a relationship with your most unstable charge RN and get them to start spreading viscious rumors about the MLP? File an anonymous complaint with HR regarding sexual misconduct with a patient or drug diversion?

 

[TooMuchResearch]

This. I'm changing my previous salary requirement. This should be a $500 an hour job.

If you do the math, even with 25% off the top for expenses, that should quite literally be a $500+/hour job. It would be for our group. But we also wouldn't staff like that.

I guess I don't know how long these nights are though.

 

[TooMuchResearch]

If you do the math, even with 25% off the top for expenses, that should quite literally be a $500+/hour job. It would be for our group. But we also wouldn't staff like that.

I guess I don't know how long these nights are though.

Edit: if they are 11 hour shifts, the math is different

 

[TooMuchResearch]

275 is the norm for 2 patients an hour with a decent pay or mix if you don’t work for a predatory CMG

I would say u hope you are getting rvu

I now rarely put in central lines unless I can’t get access or have bad access. You can run pressors peripherally

Also the ICU can do it if they need to. If I’m placing a central line I make sure pressors are running peripherally

That's underpaid if acuity is high.

 

[TooMuchResearch]

You can run pressors peripherally... but the evidence supports this with 20 gauge or higher in the AC or higher and the nurse checking every hour.

The 22 gauge in the hand that I get often under the guise of "but but but peripheral pressors" is not evidence based as safe.

Also if your PLP is seeing 1 PPH, train them to do the monkey skills like CVC placement. I'd rather have that then having the ED PLP trying to admit a burn patient to the ICU who has 2 separate indications for transfer to a burn center, but never presented the patient to the burn center.

Where am I going to get the lines necessary to train them to do central lines? Medical residency?

 

[RustedFox]

Where am I going to get the lines necessary to train them to do central lines? Medical residency?

I'd rather they didn't do lines at all.
Jesus, they're a mess.

 

[WorkNoteEmergency]

As much as I want to dislike mid levels, the ones I work with are fantastic. They don’t make mistakes and know their limits. And they’re just great people too.

That has traditionally been my experience but they're all leaving and getting replaced with newbies or ones who bounce around jobs. The good ones burn out and move to other specialties. We had one who was really, really good; (I seriously looked forward to working with him more than some of our new docs), applied to medical school, I called my alter mater admissions director to recommend him but he didn't get in because of "not enough volunteer work". By that point he saw where medicine is heading and he gave up on that and now WFH for one of the big EMRs, makes same money as before. I'm sure within 10 years he'll be a VP making close to MD money without the debt.

Besides him, we've lost experienced MLP's to primary care, ENT, Pulmonary/Crit care.

 

[ScepticSkeksis]

This is why I've always thought MLPs should have a productivity component. It encourages them to pick up more patient and not just sit and slack off. Unfortunately there tends to be a lot of resistance to this and my current place there was nearly an open rebellion when management suggested we got to productivity for them.

 

[Brigade4Radiant]

That has traditionally been my experience but they're all leaving and getting replaced with newbies or ones who bounce around jobs. The good ones burn out and move to other specialties. We had one who was really, really good; (I seriously looked forward to working with him more than some of our new docs), applied to medical school, I called my alter mater admissions director to recommend him but he didn't get in because of "not enough volunteer work". By that point he saw where medicine is heading and he gave up on that and now WFH for one of the big EMRs, makes same money as before. I'm sure within 10 years he'll be a VP making close to MD money without the debt.

Besides him, we've lost experienced MLP's to primary care, ENT, Pulmonary/Crit care.

This is happening on a national level EM is what midlevels do early on in their careers and then they leave to do other things