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NP attending at FM residency

Discussion in 'Family Medicine' started by LeroyJenkinsMD, Oct 26, 2018.

  1. LeroyJenkinsMD

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    A resident physician checking out patients to a nurse practitioner with no attending available. ACGME violation? How to report?
     
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  3. Blue Dog

    Blue Dog Fides et ratio.
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  4. LeroyJenkinsMD

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    Will the complaint be investigated if submitted anonymously?
     
  5. nwciowa

    nwciowa Assistant to the Regional Manager
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    Is this NP faculty at the program in question?
     
  6. sb247

    sb247 Doer of things
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    During med school I was at a clinic with docs and midlevels. When the docs were all gone at the same time the resident would leave
     
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  7. CCM2017

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    You cannot file a “formal complaint” anonymously but you can report an issue anonymously to the “Ombudsperson”. See below.

    “The Office of the Ombudsperson offers an opportunity to anonymously report issues about residency programs and institutions without impacting their accreditation or Recognition status. Allegations presented to this office may or may not rise to the level of chronic and/or routine non-compliance with ACGME program or institutional requirements, but they should be within the scope of the ACGME’s oversight.”

    Source: https://www.acgme.org/Residents-and-Fellows/Report-an-Issue/FAQs
     
  8. smq123

    smq123 John William Waterhouse
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    No, the good ones will tell you that they're nurses, first and foremost. Actually, at my last job, doctors got gifts on Doctor's Day, and the NPs got gifts during Nurses's week.
     
  9. W19

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    How do programs get away with stuff like that?
     
  10. hello1234!

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    Is this a regular thing?!?!?!??!????
     
  11. petegriffin

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    I remember psych residents at a prestigious med school in Texas rounding with a psych NP and the senior psych residents were checking out to her...no disrespect...but I feel embarrassed for the psych residents. The psych NP looked very experienced...but I would not feel like that is good training.

    I've also seen nurse midviwes helping non-OB residents/med students deliver. I've seen CRNAs helping anesthesia interns intubate. I've seen ER PAs precepting ER interns do central lines.


     
  12. LeroyJenkinsMD

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    This will not become a regular thing if physicians stop putting up with it. This is academic laziness at its finest. Residents doing all of the work/notes wasn’t enough so now attendings don’t even have to be present, just hire an NP. It’s fradulent.

    I was going to mention this to faculty, and say look if this is appropriate then you won’t mind me telling all of the applicants this year, but that just puts a target on my back. Anonymous complaint to ACGME is best. If enough of those stack up hopefully it will be handled.
     
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  13. Lexdiamondz

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    I think there's a difference between being observed for procedures and learning management from a preceptor. Anyone really can learn a procedure - it requires manual dexterity and that's about it. I have no issues with learning CVLs from PAs or intubating with a CRNA. If you've done more of something than I have, by all means teach me.

    Management, however, is a totally different story. The difference between an MD and a midlevel is in the fund of knowledge and experience that informs our clinical decision making and you should only be learning management from an attending or senior resident - anything short of that should be reported to the ACGME.
     
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  14. CCM2017

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    I want to agree with you... But this is just how it starts.

    I am of the opinion that NURSES have no business supervising resident PHYSICIANS. I’m willing to bet the ACGME agrees.
     
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  15. LeroyJenkinsMD

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    It’s really time that specialties come together on this one guys. We need a separate society among all specialties that just deals with mid levels.
     
  16. septoplasty

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    That's a personal approach though, makes no sense to learn it from someone who shadowed a physician, that's going to lead to broken telephone situation. I suppose a straight forward uncomplicated procedure outcome is fine, but what happens when you run into an issue, or some variation with the patient.. NP's/PA's get bent out of shape because of this, and this isn't the scenario you want the physician to be in after theyre "trained" for a procedure. After all, if he/she screws up, gets litigated, the court/lawyers will laugh when they say 'that's what I was taught by midlevels'.
     
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  17. Lexdiamondz

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    I agree, there's a huge difference between learning a technically uncomplicated procedure from a midlevel and doing one with variations in haemodynamics, anatomy, etc. I was mostly speaking to the former, rather than the latter.

    With that said, I will admit that the majority of my learning as a resident has come from learning how to troubleshoot difficult procedures on my own, which requires having done enough of them to know when you're in over your head.
     
  18. hallowmann

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    Like no attending even available by phone? Depending on the service, sometimes you handoff to NPs and mid-levels the same way you would handoff to another junior resident, with an attending present only at home. Its not like you answer to them, right? As long as someone is available if things go wrong (like an attending or fellow by phone), I think you're OK. Another example is the ED at shift change where you sometimes handoff to PAs as well as residents.

    This actually happens at a lot of places. They're getting paid more than you. If you handing off to them means less night float for you, I think that's fine for your learning. Its not like you're doing less hrs, because unlike them, you're there for 6 days/wk as opposed to 3-4.
     
  19. LeroyJenkinsMD

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    NP hogs majority of certain office procedures. Other residents, PGY2+ still have not done some of the procedures the NP does commonly. Random attendings are in house and available by phone, but none are scheduled to be available.
     
  20. MedicineZ0Z

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    See, I told you in another thread. And you didn't believe me that this happens, lol.
     
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  21. SLC

    SLC Lock, Step, & Gone (Graduated!!!)
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    In my residency, we spent some time in a women’s hospital that housed a pretty well respected OB-GYN residency. They had a whole cadre if CNM’s that were treated like faculty. They ran the vaginal delivery service for the OB residents, and they worked OB triage. They also apparently got the biggest say in how to form each year’s residency rank list.

    I’d precept with them (sorta) in OB triage. The thing is they couldn’t sign my notes, they had to write their own note in addition to mine. They were awful to work with too, huge chips on their shoulders. They’d second guess everything we did, is make a DX of BV and they’d demand to see the wet mount. I’d check a patient’s cervix and they’d tell me I couldn’t send them to L&D until they double checked it. This after a year on our FM OB service where the interns did this type of thing all day every day. I’d probably seen 250-300 cases in our home hospital’s OB triage and L&D service before even going there. These nurses saw it as their mission to come down on FM whenever possible, and were in general just terrible people. But in the end, I learned to play their game and just skate through my month in OB triage. Kill them with kindness I suppose.
     
    #20 SLC, Nov 3, 2018
    Last edited: Nov 3, 2018
  22. SXMMD

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    More common than you think... and it's a complete joke. Workplace politics, regional needs, financial circumstances are some of the reasons it happens. Hope your situation improves. I agree anonymity is probably the best route
     
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  23. hallowmann

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    Yeah, that's not happening at my program. That would suck. NPs on services definitely hogged certain procedures, but when we're on procedure clinics or just have a clinic procedure for COC its us doing it. Also, so the NPs are actually the staff on inpatient? That doesn't make any sense to me at all.
     
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  24. nlax30

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    Certainly a product of the current medical institution. NPs are being pushed by administration to become more clinically active, independent and productive since that means they can bill their own RVUs..... more $$ for the hospital/group. No longer just ‘physician-extenders’ but extra billers ultimately that can improve the bottom line the admin’s eyes.

    That said obviously there is wide range in how they view themselves and i guess fortunately in that I’ve worked with terrific NPs and PAs. At least in my field they function as a useful part of the team and really defer to me as the fellow so usually it’s them staffing things with me and not the other way around (obviously ultimately they attending is in the loop).

    As a resident early on in your career I can see where there is some room for you (collective) to learn certain aspects (clinical or procedural) from an experienced NP or PA. We learn things all the time from experienced nurses, this isn’t much different. I deal with industry reps in my field which is heavily technology oriented and there are always new gadgets, devices or techniques coming out where I actually learn a specific procedural skill or use of a device from the rep themselves.

    Not to sound cliche but everyone has a role and there are things we can take from other people on the ‘team’. That said, if you’re routinely having to staff patients with an NP/PA then that’s an issue with the program. If you’re just signing out a patient to them for coverage issues then that’s not an issue in my opinion.
     
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  25. MedicineZ0Z

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    How do they hog procedures from residents? Also why is a nurse even doing a physician procedure?
    Yeah... no. Just cause someone can do something, doesn't mean they should. Medicine needs some hard liners or it's getting swallowed up as a whole. It'll eventually turn doctors into just being medical managers who supervise 5-6 midlevels (already happening with anesthesia).
     
  26. nlax30

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    So what part specifically do you not agree with?
     
  27. MedicineZ0Z

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    An NP or PA should not supervise a doctor, ever. It's one thing to give little on the job pointers to a july intern, but that really needs to be the extent of it. You have CRNAs overseeing seniors intubate, NPs overseeing lines put in, where does it end? When you allow one thing through, it all comes in. There's no moderation in this business, period.
     
  28. hallowmann

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    As an off-service rotator on say a surgical specialty, the PAs and NPs often go out of their way to take procedures or the attending just prefers for them to do it rather than go through the additional guidance necessary to show an off-service resident how to do it.

    As an example, I was in a rotation, and I made it very clear to the residents and staff that I wanted exposure to X procedures, because they're commonly done in primary care. One of the staff there was an NP, and I was unfortunate enough to be there the same time as a new NP was joining and being trained. They went out of their way to give her as many procedures as they could, so I was often left with only a few, when she wasn't around like on lunch or when it was the last patient of the day (because the NPs always left early). It was a pretty poor experience for me as a result. What made it worse was that it was abundantly clear that I had far more training in that off-service field, which admittedly was minimal, than this brand new NP, let alone medicine in general. All of it was pretty annoying, and you can believe I complained about it to the PD, but the experience is essentially dictated by the other service.
     
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  29. Stagg737

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    You should tell the incoming applicants anyway. If I were an intern and was supervised by an NP and was never told about it at the interview I'd reem my upperclassman out. If my PD or any other attending in my program said that we'd start being supervised by NPs I'd let them know that I was not okay with it and would not participate. If they had a problem with that I'd let them know I'd be looking at other programs. The NP lobby has made it very clear that they practice nursing and not medicine, so it is inappropriate for residents to be supervised by them since they aren't practicing the same field.

    In independent practice states nurses are being hired to staff patients just like physicians do. I'm in a physician's FB group and a few months ago there were several docs on there who said their employers (hospitals) had hired NPs and required the physicians to train them to work on the unit. After the NPs were trained, the physicians were promptly fired. So the docs trained their own NP replacements who were then seeing patients unsupervised. Welcome to the new reality of medicine.
     
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  30. hallowmann

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    That's just depressing...
     
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  31. MedicineZ0Z

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    Quite insane. This should go to the ACGME, not the PD. I mean this is nothing short of a disgrace.
    Attendings wanting to load their pockets pre-retirement and being complete sell outs. It shows the lack of self-respect.

    If the ACGME had any balls it would strike the hammer down in a very broad way to punish anyone and everyone who allows this sort of thing. Throw everyone involved under probation and do it nationwide, it'll change things very quickly.

    It's wayyyy more common than you think to be supervised by a midlevel on off-service rotations.

    lol.


    Now you see why I said this takes a hardline stance above?
     
  32. Stagg737

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    Not in the states I went to med school in or in my residency state. None allow mid-levels to have independent practice rights and I know of zero situations in my area(s) where students or residents were actually supervised by mid-levels. Taken to see a patient here or there or taught a basic procedure like inserting a foley? Sure. Actual supervision? No. In fact I don't think my program even employs mid-levels in my field other than psychologists, which is fine with me since they're not trying to prescribe here and we basically just learn therapy with them.
     
  33. septoplasty

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    This is a point-to-note ACGME violation that has its own "section" on the annual survey you get. I would set this **** on fire and see it blow up. As someone above said, let the hammer come down, and watch it burn.
     
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  34. MedicineZ0Z

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    This is why you can't place nice with them. It takes a hard line approach with no moderation/flexibility.
     
  35. nlax30

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    Unfortunately I don’t see our medical societies standing up for us in any way regarding this issue.
     
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  36. Blue Dog

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  37. MedicineZ0Z

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    The problem with just opposing independence is that "supervision" nowadays barely means anything. There needs to be strict guidelines put in place for licensing midlevels. Even if insurance companies don't care, licensing bodies can mandate something that enforces strict supervision.
     
  38. Blue Dog

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    Medical/nursing licensure and supervisory requirements vary from state to state. Not sure what insurance companies have to do with it, unless you're talking about things related to payment (e.g., "incident to" billing, etc.)
     
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  39. MedicineZ0Z

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    Well insurance companies are okay with compensating for services where the physician never saw the patient themself, that's an enormous issue of its own.
    If there's a crackdown from the physicians side, where co-signing isn't considered adequate - then there's no choice but for employers to make changes.
     
  40. Blue Dog

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    Paid at 80% of the physician rate if not "incident to," but...whatever.

    I still don't know what you're advocating for. What's "strict" supervision in your opinion...?

    Don't get me wrong, I'm not on their side. But, if you want to be on my side, you need to do your homework and have some coherent basis for your arguments. Otherwise, it just looks like a turf battle.
     
    #39 Blue Dog, Nov 9, 2018 at 6:51 PM
    Last edited: Nov 9, 2018 at 6:59 PM
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  41. MedicineZ0Z

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    Strict supervision means the physician must still see the patient face-to-face... The midlevel can do the paperwork obtain the history etc.
     
  42. Blue Dog

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    So, if that were the case, why would anyone bother hiring midlevels...? An MA can take a history, and it would take as long (or longer) for me to review and confirm a history that somebody else took than it would to just do it myself.
     
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  43. MedicineZ0Z

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    It would still save time if utilized correctly (physician does the assessment/plan only). Also, they save a lot time via completion of all paperwork.
    Could also separate out quick visits into two levels where the refills and very quick follow-ups is done by the midlevel.

    But yes, there'd be a significant decrease in the market demand. The opposite is currently true where they can swallow physicians up and have them for lunch.

    Midlevels should have the same role as an early 4th year med student essentially and should stop being treated like they're residents. If they're a PA, they do an easy version of 2nd and 3rd year med school, easier exams and a much muchh easier board exam - then they're magically a resident. If they're an NP, they can now do online courses + few months of shadowing an NP and they're good to go. So I never understood why midlevels are treated like they're somehow as good as a resident? When you don't even know how an ACE inhibitor works or what the indications for a chole are, you have no business treating patients without full supervision.
     
  44. Blue Dog

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    I guess that makes sense when you're a med student. Report back in a few years.

    In the real world, there is no such thing as a "refill" or "quick follow-up" visit. Nothing is straightforward until you prove it to be so.

    I've read that sentence several times, and still don't know what it means. Midlevels aren't treated like residents.

    That didn't help...
     
  45. MedicineZ0Z

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    This model is already used in Canada for the most part. Meaning proof of concept exists.
    Of course they are. That's how countless people have described them, even on these forums.
     
  46. Blue Dog

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    I don't live in Canada, and I don't think the US has any obligation to follow Canadian policy (don't get me started).

    Citing SDN as a source is worse than citing Wikipedia...
     
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  47. MedicineZ0Z

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    lol that's like saying a business model in another state is useless. When a model works in a very similar system, it means it's viable.

    I'm saying many share that perspective. Also, I don't see this back and forth arguing on midlevel forums. Their mentality is divide and conquer at all costs.
     
  48. Blue Dog

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    Um...no, it doesn't. Canada isn't the US. If that doesn't make immediate sense, there isn't anything I can do to help you.

    Now you're playing the Donald Trump card... "Many people say such-and-such...!" I think I'm done with this convo. Thx. It's been real...
     
  49. sunshinefl

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    I’m an M2 and this already doesn’t make sense to me. I wouldn’t want to be put in a position to make a diagnosis and plan based on someone else’s history and physical presented to me. (I honestly think that would be worse than signing off on a completed chart, which I’m already not thrilled about). In school they pound us with the diagnosis is 90% about artful history-taking. Also, when we conduct SP exams in small groups in clinical medicine, which is one student of the group conducting the H&P, everyone else silently watching, and everyone doing their own SOAP note including a DDx and plan, I always find this so much more difficult than when I conduct the H&P. Because I might have wanted to explore a different line of questioning, or had lingering questions, and the approach to the H&P wasn’t mine and it’s hard to shift from their track for the H&P to mine for the A&P.
     
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  50. Stagg737

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    No, they're treated like physicians, especially in independent practice started. Which is even worse and more insane given the incredible lack of foundational education they have.

    Go read some ignore the attending forums and you'll see that many attendings sign off on mid level charts without even reading the H&P portion of the note. The pressure by administration to push as many patients through the ED and clinics as possible has led to this and many physicians "just go with it" and if something happens the hospital's liability and malpractice insurance covers it. Again, welcome to the new world of medicine.

    I'll also add that since I went to your med school that the what is taught in terms of how you SHOULD practice does not always align with what is actually done or even what is realistic. There are also some patient encounter which legit last 5 minutes or less and are just "refill" appointments or "quick follow-ups", but this will vary significantly based on your field.
     
    MedicineZ0Z likes this.
  51. MedicineZ0Z

    2+ Year Member

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    Med school version vs real world.
     

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