Midlevels in Neurocritical care

[throwawayNCC]

What is the thought on the current situation of midlevels in NCC and how is it effecting the Job Market and Marketability of adding two long years of fellowship?

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[sharkbaitwhohaha]

From what I have seen them do in the NCC... I think physicians are good. But might limiting market some if hospitals are willing to sell out and have NPP cover nights.

 

[stevresidentp]

Lots of them.. it’s somewhat concerning, i don’t know how much though.

 

[Postictal Raiden]

Not only in neurology, midlevel encroachment is very prevalent in every critical care subspecialty. I guess the tightly controlled algorithmic environment makes it easy for NPs to thrive in.

 

[grt398]

It's an issue across all specialties, but particularly hospital based specialities like EM/hospitalist/critical care. The level of care being provided in many cases is questionable, but since there doesn't seem to be any financial penalty for poor outcomes in the ICU, I'm not sure it's going to change anytime soon. Critical care done well is nowhere near as algorithmic as people outside the specialty seem to think, and the consequences of getting it wrong are pretty severe for the patient.

 

[neglect]

This is becoming a huge problem. Deeply unqualified NPs are being trained to perform reflexive actions in medicine, which work until they don't. NP mills are literally churning out people who know nothing, and did a final paper about URM hypertension clinics, but think they are equivalent to doctors. It is just unbelievable that hospital admins are willing to see patients die rather than put qualified people in proper roles.

People will die, then the pendulum will swing back. And a doctor will always have to supervise the NP in these cases.

 

[neglect]

It's an issue across all specialties, but particularly hospital based specialities like EM/hospitalist/critical care. The level of care being provided in many cases is questionable, but since there doesn't seem to be any financial penalty for poor outcomes in the ICU, I'm not sure it's going to change anytime soon. Critical care done well is nowhere near as algorithmic as people outside the specialty seem to think, and the consequences of getting it wrong are pretty severe for the patient.

Try telling this to a hospital admin. You'll be one of two who cover 3 NP's per 24 hour period. That's the model. It'll take a long time for enough people to be killed and maimed by NP care before the public gets it and starts to refuse inpatient NP care.

 

[Splenda88]

This is becoming a huge problem. Deeply unqualified NPs are being trained to perform reflexive actions in medicine, which work until they don't. NP mills are literally churning out people who know nothing, and did a final paper about URM hypertension clinics, but think they are equivalent to doctors. It is just unbelievable that hospital admins are willing to see patients die rather than put qualified people in proper roles.

People will die, then the pendulum will swing back. And a doctor will always have to supervise the NP in these cases.

People will die for sure, but I am not sure the pendulum will swing back...

 

[neglect]

People will die for sure, but I am not sure the pendulum will swing back...

Sadly I think the pendulum will swing back for those who can afford it. We are heading into a two tier system.

 

[Telamir]

Is this a “they took er jerbs” moment?

I haven’t aseen this be an issue with the exception of them being procedure monkeys. That being said, they can only do that in places where people are salaried and not on production cause otherwise you’re just shooting yourself in the foot.

Honestly the more I work with NPs the less intimidated I am. Maybe I’m naive and don’t see the obvious apocalypse coming.

 

[neglect]

Is this a “they took er jerbs” moment?

I haven’t aseen this be an issue with the exception of them being procedure monkeys. That being said, they can only do that in places where people are salaried and not on production cause otherwise you’re just shooting yourself in the foot.

Honestly the more I work with NPs the less intimidated I am. Maybe I’m naive and don’t see the obvious apocalypse coming.

They suck, but they are cheap. If you are employed, do you think your employer values high skill for every patient you see? Or are they looking at you like a very expensive commodity that just got a lot more expensive compared to the two or three NP salaries you cost them?

The more I see, the more I realize how dangerous (to patients) they are. They have no clue what they are doing and no clue they suck. Like incapable of relating a medical history. Like incapable of thought. Like incapable of thinking "OK, pre-test probability was low, so am I looking at a false +?"

Not an apocolypse. Still stinks if you are the one who ends up dead or maimed because an NP can't diagnose X.

 

[sharkbaitwhohaha]

While you might not be scared of NPs...you should be scared of the AANP. They are very effective lobbyist and it won't matter that NPs are a threat to patients.

 

[blue.jay]

There is no doubt about NPPs poor knowledge base and analytical skill. They are good at following algorithms, consulting or shifting blame on supervising physician. They are very cheap too. These are very desirable qualities for hospital admins. They don't give a **** about your knowledge or skill. MDs are seen as unwanted expense and a liability sponge. Ultimately all these big hospitals are smart enough to not fire docs and have NPs run the show, instead they force you to oversee 2-4 midlevels instead of hiring you a partner. If there are bad outcomes, it's on you. Hence there is no way to say that midlevels give poor care. Of course if the do better it's published but if they kill a patient trying to do something beyond their scope the supervising MD is blamed and sued.

 

[blue.jay]

I don't think the two tierd argument applies for hospital based specialities. Even in big places like Cleveland Clinic; midlevels are more rampant than doctors in ICU, ED, consults and floors. I am saying because the wealthy will come to CCF based on #2 us hospital rank but are ultimately seen by midlevels from ED to discharge. Every health system wants to make as much $$$ as they can which means more midlevels and bare minimum of expensive doctors for namesake supervision and liability.

 

[sharkbaitwhohaha]

For those SDN lurkers (premed, med students, residents, fellows, attendings, other), please advocate for your patients and yourselves.

Do this by the following:
-join Physicians for Patient Protection
-join the AMA
-join your state medical society (often more active for physician goals)
-if inclined, get involved with those groups by apply for a committee, etc.
-if in training or practice and looking for a new job, join a physician owned group (not hospital based, no MBA owner, no midlevel owner)
-be vocal when you see a midlevel cause harm or a near miss for a patient.

End rant

 

[xenotype]

For those SDN lurkers (premed, med students, residents, fellows, attendings, other), please advocate for your patients and yourselves.

Do this by the following:
-join Physicians for Patient Protection
-join the AMA
-join your state medical society (often more active for physician goals)
-if inclined, get involved with those groups by apply for a committee, etc.
-if in training or practice and looking for a new job, join a physician owned group (not hospital based, no MBA owner, no midlevel owner)
-be vocal when you see a midlevel cause harm or a near miss for a patient.

End rant

Have to be careful about being vocal about this when you work for a large health system or are still in training. Incident reporting and QI can be used as a somewhat safe mechanism but often these are not very anonymous in reality. Politics are in every hospital, and getting on the bad side of admin or a division chief is a terrible hill to die on as a new physician without much financial flexibility. They can always report you as a 'disruptive physician' to the NPDB and destroy your career, and lawsuits to fight this are not particularly effective and very expensive- meanwhile you are out of work for months/years with a black mark.

 

[Telamir]

I will also say if you’re going to be “vocal” be careful. I recently saw a med student get screwed in the “professionalism” front because he made an off hand comment about NPs and the NPs got offended. This ended up making it to the clerkship director who likes the NPs he works with and next thing you know—disciplinary hearing.

i don’t think it’s worth shooting your self in the foot like that.

 

[throwawayNCC]

With all these issues in mind, have you noticed decrease job opportunities in NCC as opposed to other Neurology subspecialties ?

I also noted this video that was somewhat concerning:

 

[blue.jay]

I am guessing ICU will have a similar fate like EM. I can foresee most hospitals giving away ICU staffing contracts to CMGs or teleICU groups who will use more midlevels than doctors. Probably doctors will do mostly tele work covering 2 or more ICU which will have NP in unit. Of course higher acuity referral centers and academic centers will be immune due to much cheaper resident/fellow workers and their teaching staff.

 

[Telamir]

Considering the fact that most of the nurses that I see at my hospital getting/finishing NP degrees are having some trouble finding a job I don’t know that the situation is quite as apocalyptic as people seem to suggest.

the places I have seen using tele icu tend to be small hospitals in places no one wants to work at who are on top of that horrible at retaining physicians. That being said it’s an N of 2 in my experience but still.

 

[xenotype]

NPs without previous experience of 2+ years directly in the relevant specialty won't be able to get a job anywhere pretty soon. Even primary care I predict. Bascially every RN is 'working on' an online NP degree and they have so many diploma mills.

 

[TwistedTea]

Lol neurology at one of the hospitals we rotate at for residency is almost worthless bc it’s all np and the attending trusts them way too much. Almost pointless to consult them for anything besides Tpa (actually get the attending for those calls) but since they don’t do anything you Might as well be asking an ms3 for their opinion on the patient.

at least we learn to manage neuro good. Sad it’s a level 1 trauma center.

so some doctors are sell outs too not just the hospital.

 

[Mad Jack]

It's an issue across all specialties, but particularly hospital based specialities like EM/hospitalist/critical care. The level of care being provided in many cases is questionable, but since there doesn't seem to be any financial penalty for poor outcomes in the ICU, I'm not sure it's going to change anytime soon. Critical care done well is nowhere near as algorithmic as people outside the specialty seem to think, and the consequences of getting it wrong are pretty severe for the patient.

I was going to say, critical care is amongst the least algorithmic areas in medicine, as you're often working at the far limits of medicine for which there isn't a great deal of data and you need to use a strong understanding of basic science and what literature exists to guide you in all but the most routine cases. NCC is more limited in scope to some degree than MICU work, but I'd assume the same principle applies

 

[Postictal Raiden]

I was going to say, critical care is amongst the least algorithmic areas in medicine, as you're often working at the far limits of medicine for which there isn't a great deal of data and you need to use a strong understanding of basic science and what literature exists to guide you in all but the most routine cases. NCC is more limited in scope to some degree than MICU work, but I'd assume the same principle applies

I'm in no way advocating for more profession creep, but I disagree with the sentiment that CC is less algorithmic and more prone for causalities from midlevel's incompetence. Unlike in outpatient where midlevels have very little to no oversight when encountering completely undifferentiated cases, in the ICU, NPs/PAs have a very defined role and, very often, there are multiple specialties involved where a large screw up hardly goes unchecked.

The role of the midlevel at my institution is basically to follow up on Na and Cr for cerebral edema patients on osmotic therapy, following up on serial CTs/TCDs on SAH, and following up on the EEG reads for patients with status and making the appropriate AED adjustments recommended by the epileptologist.

Contrast that to the uninhibited NP running an UC who missed a SAH in a young female patient on OCPs, and shrug it off as a sinusitis pain and put pt on more NSAIDs. Or the outpatient neurology NP who missed MMN and diagnosed the patient with ALS, causing the patient to miss out on a year's worth of IVIG treatment.

 

[grt398]

I'm in no way advocating for more profession creep, but I disagree with the sentiment that CC is less algorithmic and more prone for causalities from midlevel's incompetence. Unlike in outpatient where midlevels have very little to no oversight when encountering completely undifferentiated cases, in the ICU, NPs/PAs have a very defined role and, very often, there are multiple specialties involved where a large screw up hardly goes unchecked.

The role of the midlevel at my institution is basically to follow up on Na and Cr for cerebral edema patients on osmotic therapy, following up on serial CTs/TCDs on SAH, and following up on the EEG reads for patients with status and making the appropriate AED adjustments recommended by the epileptologist.

Contrast that to the uninhibited NP running an UC who missed a SAH in a young female patient on OCPs, and shrug it off as a sinusitis pain and put pt on more NSAIDs. Or the outpatient neurology NP who missed MMN and diagnosed the patient with ALS, causing the patient to miss out on a year's worth of IVIG treatment.

Other CCM attendings are welcome to disagree with me if they have different experience, but I really think you're underestimating the defined role of midlevels in most (perhaps some is the better phrase?) non-tertiary level ICUs. Midlevels are the only people in house from ~5pm-6 or 7am in many medical/surgical ICUs, including some I've worked in. They do not have to call anyone, for any reason, unless they feel the need. They intubate, do lines, chest tubes and anything else that they feel comfortable with solo. They are not staffing anything overnight with the attending unless they want to. I've seen key missed diagnoses like very clear cardiogenic shock mistaken for septic shock, inappropriate antibiotics (giving unasyn for pseudomonal bacteremia), broad spectrum antibiotics for "bilateral cellulitis and sepsis" in a patient >20 lbs up from their dry weight who came in with worsened dyspnea/normal WBC/elevated BNP/CXR c/w increased interstitial edema and no signs of infection, and a whole host of inappropriate ventilator management.

I'm not saying there aren't serious issues for outpatient as well, but my focus is CCM, so I see the result of the aforementioned examples. There are very good midlevels too, but there just isn't the same level of consistency that you get with physician training.

 

[Postictal Raiden]

Other CCM attendings are welcome to disagree with me if they have different experience, but I really think you're underestimating the defined role of midlevels in most non-tertiary level ICUs. Midlevels are the only people in house from ~5pm-6 or 7am in many medical/surgical ICUs, including some I've worked in. They do not have to call anyone, for any reason, unless they feel the need. They intubate, do lines, chest tubes and anything else that they feel comfortable with solo. They are not staffing anything overnight with the attending unless they want to. I've seen key missed diagnoses like very clear cardiogenic shock mistaken for septic shock, inappropriate antibiotics (giving unasyn for pseudomonal bacteremia), broad spectrum antibiotics for "bilateral cellulitis and sepsis" in a patient >20 lbs up from their dry weight who came in with worsened dyspnea/normal WBC/elevated BNP/CXR c/w increased interstitial edema and no signs of infection, and a whole host of inappropriate ventilator management.

I'm not saying there aren't serious issues for outpatient as well, but my focus is CCM, so I see the result of the aforementioned examples. There are very good midlevels too, but there just isn't the same level of consistency that you get with physician training.

😱
I didn’t realize they acted so autonomously at other institutions. This is scary and quite disturbing

 

[Splenda88]

😱
I didn’t realize they acted so autonomously at other institutions. This is scary and quite disturbing

Well, it's pretty scary out there...

The problem with midlevel is their arrogance TBH. I don't know if it's overcompensation for their lack of 'knowledge' or whatever. One thing I Iike about medicine is that: Most physicians know when they are in over their head. My colleagues (even the best ones in my program) always try to bounce idea with other residents when they are not 100% sure. Mid levels do not seem to like doing that...

 

[Postictal Raiden]

The more you know, the more you realize how much you don’t know.

 

[grt398]

One thing I Iike about medicine is that: Most physicians know when they are in over their head. My colleagues (even the best ones in my program) always try to bounce idea with other residents when they are not 100% sure. Mid levels do not seem to like doing that...

I think this is actually an exceptionally important aspect of becoming/remaining a good physician: humility. I never hesitate to ask other opinions about a challenging clinical situation, including from the nurses I work with, and I don't take it as some kind of reflection on my worth as a person if it turns out I'm wrong. I genuinely welcome it as a learning opportunity to correct some inaccurate model for some disease process I had in my head and I hope to always keep that mentality.

 

[neglect]

Well, it's pretty scary out there...

The problem with midlevel is their arrogance TBH. I don't know if it's overcompensation for their lack of 'knowledge' or whatever. One thing I Iike about medicine is that: Most physicians know when they are in over their head. My colleagues (even the best ones in my program) always try to bounce idea with other residents when they are not 100% sure. Mid levels do not seem to like doing that...

Imagine BEING an NP. You get taught that excellence doesn't matter. You get taught to follow strict algorithms that people in academics created without seeing patients. You do not understand or know anything about pathophys, pathology, pharm, epidemiology; nor can you take a decent history or understand pre-test probability of the tests you order. You are also taught that none of these things matter, that you're better than doctors. And then you hit the floors.

 

[xenotype]

Other CCM attendings are welcome to disagree with me if they have different experience, but I really think you're underestimating the defined role of midlevels in most (perhaps some is the better phrase?) non-tertiary level ICUs. Midlevels are the only people in house from ~5pm-6 or 7am in many medical/surgical ICUs, including some I've worked in. They do not have to call anyone, for any reason, unless they feel the need. They intubate, do lines, chest tubes and anything else that they feel comfortable with solo. They are not staffing anything overnight with the attending unless they want to. I've seen key missed diagnoses like very clear cardiogenic shock mistaken for septic shock, inappropriate antibiotics (giving unasyn for pseudomonal bacteremia), broad spectrum antibiotics for "bilateral cellulitis and sepsis" in a patient >20 lbs up from their dry weight who came in with worsened dyspnea/normal WBC/elevated BNP/CXR c/w increased interstitial edema and no signs of infection, and a whole host of inappropriate ventilator management.

I'm not saying there aren't serious issues for outpatient as well, but my focus is CCM, so I see the result of the aforementioned examples. There are very good midlevels too, but there just isn't the same level of consistency that you get with physician training.

Yes, this is really what passes for critical care at a lot of places these days. Even academic places with non-teaching services.

 

[TwistedTea]

Imagine BEING an NP. You get taught that excellence doesn't matter. You get taught to follow strict algorithms that people in academics created without seeing patients. You do not understand or know anything about pathophys, pathology, pharm, epidemiology; nor can you take a decent history or understand pre-test probability of the tests you order. You are also taught that none of these things matter, that you're better than doctors. And then you hit the floors.

what makes you think them hitting the floors makes them change their mind? I would say they dont even know enough to know when they are over their head.

 

[TwistedTea]

The more you know, the more you realize how much you don’t know.

They basically act as neurologists at our institution (big teaching place) but we can't get full time neuro to come here for some reason. So we basically do not consult them and figure it out ourselves. Act as in act, might as well be consulting the med students... so we just dont consult

 

[justd0it87]

As a private practice neurointensivist, I'd like to shed some light on APPs in neurocritical care. In general, I think APPs do have a role to play in neurocritical care and are quite helpful overall if your staffing model / census can support an APP logistically and financially. As someone who has trained in APP-heavy neurocritical care units in residency and fellowship, I experienced first-hand the amazing knowledge, care, and teamwork displayed by these subspecialized APPs. Now keep in mind, APPs that subspecialize and only do one branch of critical care day in and day out are a rare breed. One of the best "veteran" NSICU APPs who had been doing this for decades would still coordinate care with the supervising fellow, who she clearly had decades of experience on, just to make sure everyone is on the same page for the best care of the patient.

Now in private practice at a tertiary center, our current model supports APPs that staff multiple units / specialties of critical care so APPs are bit less subspecialized in the finer nuances of neurocritical care. That being said, their quality of care is no less and they generally run treatment plans and questions by us openly. We have a great relationship with the APPs and I also support their autonomy because we have a trusting relationship that they will come ask if they are not sure. We have a "leave your ego at home" / open communicative relationship and that goes both ways across titles. APPs discuss with attendings, junior attendings bounce questions off senior attendings. I think having this kind of practice culture fosters the utility of APPs. They can support seeing the relatively less acute ICU patients and help with consults / new admits, hold a service phone, and free up the attending to focus on what they are more trained for when you have a larger census.

Yes, there are problems with the training programs for NPs and there is a lack of standardization, the scary online programs, the bare requirements at some of these places, so I think on a systems-level, autonomy of NPs should be closely examined. I have certainly seen APPs that should not be in critical care to begin with (I have similar experiences others have posted earlier in this thread). This is either a lack of training / education issue (which IMO, is more of a "fixable" problem that comes with teaching if the trusting relationship exists with someone who is diligent / quick learner) or actually problematic, comes down to an individual / personality issue than it is a matter of their credentials of being an PA or NP.

 

[TwistedTea]

As a private practice neurointensivist, I'd like to shed some light on APPs in neurocritical care. In general, I think APPs do have a role to play in neurocritical care and are quite helpful overall if your staffing model / census can support an APP logistically and financially. As someone who has trained in APP-heavy neurocritical care units in residency and fellowship, I experienced first-hand the amazing knowledge, care, and teamwork displayed by these subspecialized APPs. Now keep in mind, APPs that subspecialize and only do one branch of critical care day in and day out are a rare breed. One of the best "veteran" NSICU APPs who had been doing this for decades would still coordinate care with the supervising fellow, who she clearly had decades of experience on, just to make sure everyone is on the same page for the best care of the patient.

Now in private practice at a tertiary center, our current model supports APPs that staff multiple units / specialties of critical care so APPs are bit less subspecialized in the finer nuances of neurocritical care. That being said, their quality of care is no less and they generally run treatment plans and questions by us openly. We have a great relationship with the APPs and I also support their autonomy because we have a trusting relationship that they will come ask if they are not sure. We have a "leave your ego at home" / open communicative relationship and that goes both ways across titles. APPs discuss with attendings, junior attendings bounce questions off senior attendings. I think having this kind of practice culture fosters the utility of APPs. They can support seeing the relatively less acute ICU patients and help with consults / new admits, hold a service phone, and free up the attending to focus on what they are more trained for when you have a larger census.

Yes, there are problems with the training programs for NPs and there is a lack of standardization, the scary online programs, the bare requirements at some of these places, so I think on a systems-level, autonomy of NPs should be closely examined. I have certainly seen APPs that should not be in critical care to begin with (I have similar experiences others have posted earlier in this thread). This is either a lack of training / education issue (which IMO, is more of a "fixable" problem that comes with teaching if the trusting relationship exists with someone who is diligent / quick learner) or actually problematic, comes down to an individual / personality issue than it is a matter of their credentials of being an PA or NP.

I dont think anyone is arguing their use, but from AANP and AANC def missed the "leave ego at home" boat. what you describe are exceptions not the norm. Individual mid levels may not be the issue, but the fact that their mother organizations think that are superior to physicians.... that is the problem. I am personally not afraid of losing jobs to them but its not due to the fact that they are good or play nice, its the fact that most are just not even close to competent. And I think anyone can succeed in a very narrow niche, that isn't necessarily something to be proud of.

 

[neglect]

They basically act as neurologists at our institution (big teaching place) but we can't get full time neuro to come here for some reason. So we basically do not consult them and figure it out ourselves. Act as in act, might as well be consulting the med students... so we just dont consult

NO, don’t you get it? Clearly you have not experienced first-hand the amazing knowledge...

Yeah, it is just sad. I hope you attract some good doctors, but if the hospital won’t support doctors, then they won’t come. Sadly this is going to happen across all of medicine. It really is a problem: low paid and totally incompetent NPs take over the roles of doctors, doctors then join the ever-growing ranks of useless administrators, some just oversee herds of compliant NPs and try to prevent them from making their units into kill zones. Bedside nurses are a thing of the past. The real docs vote with their feet and leave. Patients suffer, doctors suffer, bedside nurses suffer, hospital administrators get rich.

As a private practice neurointensivist, I'd like to shed some light on APPs in neurocritical care. In general, I think APPs do have a role to play in neurocritical care and are quite helpful overall if your staffing model / census can support an APP logistically and financially. As someone who has trained in APP-heavy neurocritical care units in residency and fellowship, I experienced first-hand the amazing knowledge, care, and teamwork displayed by these subspecialized APPs. Now keep in mind, APPs that subspecialize and only do one branch of critical care day in and day out are a rare breed. One of the best "veteran" NSICU APPs who had been doing this for decades would still coordinate care with the supervising fellow, who she clearly had decades of experience on, just to make sure everyone is on the same page for the best care of the patient.

Now in private practice at a tertiary center, our current model supports APPs that staff multiple units / specialties of critical care so APPs are bit less subspecialized in the finer nuances of neurocritical care. That being said, their quality of care is no less and they generally run treatment plans and questions by us openly. We have a great relationship with the APPs and I also support their autonomy because we have a trusting relationship that they will come ask if they are not sure. We have a "leave your ego at home" / open communicative relationship and that goes both ways across titles. APPs discuss with attendings, junior attendings bounce questions off senior attendings. I think having this kind of practice culture fosters the utility of APPs. They can support seeing the relatively less acute ICU patients and help with consults / new admits, hold a service phone, and free up the attending to focus on what they are more trained for when you have a larger census.

Yes, there are problems with the training programs for NPs and there is a lack of standardization, the scary online programs, the bare requirements at some of these places, so I think on a systems-level, autonomy of NPs should be closely examined. I have certainly seen APPs that should not be in critical care to begin with (I have similar experiences others have posted earlier in this thread). This is either a lack of training / education issue (which IMO, is more of a "fixable" problem that comes with teaching if the trusting relationship exists with someone who is diligent / quick learner) or actually problematic, comes down to an individual / personality issue than it is a matter of their credentials of being an PA or NP.

I don’t get what you’re trying to say. The best extender is less than ”the supervising fellow.” So that makes the extender = resident. If a resident were to try to practice medicine without graduating, it would be practicing medicine without a license, which is illegal.

But extenders are “amazing” and you “support their autonomy.”

Also, with regard to your laudable "leave your ego at home" culture, you should meet some online NP’s who’s names end with DNP, APRN, FNP-BC, PPCNP-BC, FAANP. Here’s the president of the AANP: https://twitter.com/PresidentAANP. I stole those silly degrees from her sig. These people introduce themselves as doctors to patients.

Your “amazing” NP is going to leave what might very well be your excellent place, great culture, become unsupervised, and kill people.

 

[TwistedTea]

NO, don’t you get it? Clearly you have not experienced first-hand the amazing knowledge...

Yeah, it is just sad. I hope you attract some good doctors, but if the hospital won’t support doctors, then they won’t come. Sadly this is going to happen across all of medicine. It really is a problem: low paid and totally incompetent NPs take over the roles of doctors, doctors then join the ever-growing ranks of useless administrators, some just oversee herds of compliant NPs and try to prevent them from making their units into kill zones. Bedside nurses are a thing of the past. The real docs vote with their feet and leave. Patients suffer, doctors suffer, bedside nurses suffer, hospital administrators get rich.




I don’t get what you’re trying to say. The best extender is less than ”the supervising fellow.” So that makes the extender = resident. If a resident were to try to practice medicine without graduating, it would be practicing medicine without a license, which is illegal.

But extenders are “amazing” and you “support their autonomy.”

Also, with regard to your laudable "leave your ego at home" culture, you should meet some online NP’s who’s names end with DNP, APRN, FNP-BC, PPCNP-BC, FAANP. Here’s the president of the AANP: https://twitter.com/PresidentAANP. I stole those silly degrees from her sig. These people introduce themselves as doctors to patients.

Your “amazing” NP is going to leave what might very well be your excellent place, great culture, become unsupervised, and kill people.

Midlevels attack physicians online on a daily basis with equal care quality rhetoric but when we call it out we get shammed for being unprofessional and not being team players.

 

[justd0it87]

I dont think anyone is arguing their use, but from AANP and AANC def missed the "leave ego at home" boat. what you describe are exceptions not the norm. Individual mid levels may not be the issue, but the fact that their mother organizations think that are superior to physicians.... that is the problem. I am personally not afraid of losing jobs to them but its not due to the fact that they are good or play nice, its the fact that most are just not even close to competent. And I think anyone can succeed in a very narrow niche, that isn't necessarily something to be proud of.

Great points. I acknowledge that what and where I practice is a niche and very culture dependent between units. That's why I mentioned that on a systems-level, autonomy of NPs and lauding them better than physicians is concerning especially when there is a lack of standardization across their education.

 

[justd0it87]

NO, don’t you get it? Clearly you have not experienced first-hand the amazing knowledge...

Yeah, it is just sad. I hope you attract some good doctors, but if the hospital won’t support doctors, then they won’t come. Sadly this is going to happen across all of medicine. It really is a problem: low paid and totally incompetent NPs take over the roles of doctors, doctors then join the ever-growing ranks of useless administrators, some just oversee herds of compliant NPs and try to prevent them from making their units into kill zones. Bedside nurses are a thing of the past. The real docs vote with their feet and leave. Patients suffer, doctors suffer, bedside nurses suffer, hospital administrators get rich.




I don’t get what you’re trying to say. The best extender is less than ”the supervising fellow.” So that makes the extender = resident. If a resident were to try to practice medicine without graduating, it would be practicing medicine without a license, which is illegal.

But extenders are “amazing” and you “support their autonomy.”

Also, with regard to your laudable "leave your ego at home" culture, you should meet some online NP’s who’s names end with DNP, APRN, FNP-BC, PPCNP-BC, FAANP. Here’s the president of the AANP: https://twitter.com/PresidentAANP. I stole those silly degrees from her sig. These people introduce themselves as doctors to patients.

Your “amazing” NP is going to leave what might very well be your excellent place, great culture, become unsupervised, and kill people.

These are great points but what I wanted to point out is that there are some great team-playing NPs who know their role within the team. Although I practice within a subspecialty, this is not as rare as folks make it seem. But you are right that on a societal / systems-level, the tone that is being set that somehow NPs can supersede physicians is very concerning, which is what I was trying to address in my last paragraph.

 

[TwistedTea]

These are great points but what I wanted to point out is that there are some great team-playing NPs who know their role within the team. Although I practice within a subspecialty, this is not as rare as folks make it seem. But you are right that on a societal / systems-level, the tone that is being set that somehow NPs can supersede physicians is very concerning, which is what I was trying to address in my last paragraph.

Pretty much this. Most probably just want to work and treat patients and work under physicians as they should.

Some do the above with resent and inside think they are doctors

Then you have the Florence nightingale zealots who need no further to be described.

 

[justd0it87]

Oh, absolutely.

But I was trying to address the OPs question. NCC itself I do not believe is at threat of APP encroachment with full autonomy in the future. APPs work well within the model of NCC units and speaking to friends at other NCC units, this seems to be the case. Now I can't account for every community hospital that claims to have a NCC unit and how their structure works but "level 1" NCC units (naturally are at academic centers or tertiary community hospitals) are directed by fellowship-trained neurointensivists or grandfathered intensivists with APP backup. NCS has also released a very comprehensive set of guidelines / recommendations for standards of practice that guides MD / APP staffing as well in the past year so for the OP original question, I think there is NCS guidance that will start being looked at for how NCC units should be staffed / built. If you want to do the fellowship and love the work, go for it. Neurocritical care is an exciting field to get into and it's a great time to get in when hospitals are looking at building units across the country.

 

[nexus73]

Oh, absolutely.

But I was trying to address the OPs question. NCC itself I do not believe is at threat of APP encroachment with full autonomy in the future. APPs work well within the model of NCC units and speaking to friends at other NCC units, this seems to be the case. Now I can't account for every community hospital that claims to have a NCC unit and how their structure works but "level 1" NCC units (naturally are at academic centers or tertiary community hospitals) are directed by fellowship-trained neurointensivists or grandfathered intensivists with APP backup. NCS has also released a very comprehensive set of guidelines / recommendations for standards of practice that guides MD / APP staffing as well in the past year so for the OP original question, I think there is NCS guidance that will start being looked at for how NCC units should be staffed / built. If you want to do the fellowship and love the work, go for it. Neurocritical care is an exciting field to get into and it's a great time to get in when hospitals are looking at building units across the country.

I agree that NPs working in this setting with physician supervision is clearly reasonable and safe. If you can onboard them yourself and train them the correct way from day 1, and slowly increase their responsibilities, it can be a win win as long as they remain within a team with physician supervision. (I do resent that I had to go through a full residency making $40K ish per year while the NPs come out basically not knowing anything and get trained on the job at $100K or more per year).

However, the nursing lobby rhetoric really does not support this use of NPs. It's constant claims that they should be independent and not only are they just as good as physicians, they're better. And it's not supervision it's "collaboration". The NPs are pushing hard for complete autonomy across the spectrum, running ICUs, getting trained in surgery, ED, etc....which is extremely scary.