NPs in critical care

[ClipArtBananas]

Do you foresee demand for intensivists going down due to increased use of NPs/PAs similar to what is reportedly happening in the EM world?

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[CCM-MD]

Yes.

But nobody can say for sure. Long term future looks bleak. But recently, currently and for the near future things are looking really good.

 

[the argus]

The midlevels in the ICUs both where I did residency and now where I'm in fellowship function more like residents than independent providers. They tend to make the attending's job easier but don't necessarily increase the total number of patients that one intensivist can cover.

At least in my experience that's different than EM or hospital medicine where the midlevels function more as independent providers and overall increases the total number of patients that one physician can cover. Maybe critical care will eventually become similar but I think the complexity of patients in critical care somewhat shields against this.

 

[blue.jay]

When I started residency 6 yrs ago there were no NPs in our ICU. Now it seems like they have hired 5-6 NPs but the number of staff intensivists seem lower. Back then, they had 2 docs during day time (1 for back, procedures and to cover cardiac ICU). I think involvement of midlevels probably tightened the job market. Graduating fellows can comment more about this; as 5-10 yrs ago you can blindly pick an area on the map and get locums job but I think available jobs now especially in bigger cities are tight.

 

[ClipArtBananas]

I start fellowship this summer and won't be in the market until after my military commitment in like a decade so I'm sure things will be very different, but landscape in my community based residency program certainly seems to be shifting.

 

[Mad Jack]

In my area you basically have to wait for an attending to die to get a job in critical care. I can't imagine that an increase in midlevel involvement will help that, though it will likely make the lives of current attendings easier

 

[Flyeaglesfly]

In my area you basically have to wait for an attending to die to get a job in critical care. I can't imagine that an increase in midlevel involvement will help that, though it will likely make the lives of current attendings easier

Where is your area, I was told CC only jobs were plentiful pretty much everywhere.

 

[Mad Jack]

Where is your area, I was told CC only jobs were plentiful pretty much everywhere.

A specific state in the northeast. Right now there's a few jobs open, 4 to be precise, and none in desirable hospitals, but a few years ago there were 1 or 2 jobs available at any given time with far more applicants than positions

 

[SXMMD]

The midlevels in the ICUs both where I did residency and now where I'm in fellowship function more like residents than independent providers. They tend to make the attending's job easier but don't necessarily increase the total number of patients that one intensivist can cover.

At least in my experience that's different than EM or hospital medicine where the midlevels function more as independent providers and overall increases the total number of patients that one physician can cover. Maybe critical care will eventually become similar but I think the complexity of patients in critical care somewhat shields against this.

I think the argument about complexity is a little bit overblown. The name of the game these days seems to be “how low can we set the bar in medicine” and I suspect deaths in critically ill patients will be blamed on critical illness rather than mid level incompetence as they surge in your field.

 

[chessknt]

Unequivocally no but don’t let that stop the chicken little train.

The icu is where the **** can’t get kicked down the hill any further and time is of the essence—when you put someone who is slow or incapable of fully executing in a position like that problems occur and, in icu, people can die. When people die lawsuits can happen and the cost effectiveness of a midlevel ceases to be useful.

 

[JoeBiden69]

Unequivocally no but don’t let that stop the chicken little train.

The icu is where the **** can’t get kicked down the hill any further and time is of the essence—when you put someone who is slow or incapable of fully executing in a position like that problems occur and, in icu, people can die. When people die lawsuits can happen and the cost effectiveness of a midlevel ceases to be useful.

Most ICU medicine is highly algorithmic, and in the MICU especially most patients are old and have multiple medical comorbidities. Hospitals aren’t worried about a lawsuit from a 90-year-old with bad CHF whose cardiogenic shock was missed by an APP who thought they had sepsis and gave them vosyn.

SICU, CTICU and NICU are probably bigger landmines from a lawsuit perspective, but even in those places the surgeon is going to be the big target for lawsuits, not the CCM team.

 

[CCM-MD]

Where is your area, I was told CC only jobs were plentiful pretty much everywhere.

That is probably true right now, largely thanks to COVID. Future is uncertain.

Most ICU medicine is highly algorithmic, and in the MICU especially most patients are old and have multiple medical comorbidities. Hospitals aren’t worried about a lawsuit from a 90-year-old with bad CHF whose cardiogenic shock was missed by an APP who thought they had sepsis and gave them vosyn.

SICU, CTICU and NICU are probably bigger landmines from a lawsuit perspective, but even in those places the surgeon is going to be the big target for lawsuits, not the CCM team.

Calling it algorithmic is pretty Dunning Kruger of you. The simplest decisions in other circumstances become challenging when a patient is critically ill and a lot of thought goes into them. Poor management has disastrous outcomes. I believe midlevel encroachment is going to become a big problem but it’s not because CCM is algorithmic, it’s because of $, midlevels, hospital administrators and staffing companies.

 

[chessknt]

Most ICU medicine is highly algorithmic, and in the MICU especially most patients are old and have multiple medical comorbidities. Hospitals aren’t worried about a lawsuit from a 90-year-old with bad CHF whose cardiogenic shock was missed by an APP who thought they had sepsis and gave them vosyn.

SICU, CTICU and NICU are probably bigger landmines from a lawsuit perspective, but even in those places the surgeon is going to be the big target for lawsuits, not the CCM team.

Let me give you an example of a few people in my community icu that aren’t COVID:
1-ugib esld hard drinker 40 years old with aki withdrawing from etoh now as well
2-benzo overdose that has coverted into withdrawal with cryptic fevers to 42c
3-surgical abdominal disaster with fugemia on tpn no peripheral access
4-alcoholic cardiomyopathy Ef 10% ams transferred for aspiration hypo ventilating from benzo od given for withdrawal

You think you can create algorithms to account for each of these scenarios that a midlevel is going to follow? Do you think the midlevel is going to know about benzo dose reduction in low output chf (or better yet not using benzos), how to manage fungemia line sepsis in other no alternate access (no ID here btw), how to work up cryptic fever etc? If CCM consisted of IVF + abx next patient then it wouldn't demand extra training.

 

[JoeBiden69]

That is probably true right now, largely thanks to COVID. Future is uncertain.



Calling it algorithmic is pretty Dunning Kruger of you. The simplest decisions in other circumstances become challenging when a patient is critically ill and a lot of thought goes into them. Poor management has disastrous outcomes. I believe midlevel encroachment is going to become a big problem but it’s not because CCM is algorithmic, it’s because of $, midlevels, hospital administrators and staffing companies.

Let me give you an example of a few people in my community icu that aren’t COVID:
1-ugib esld hard drinker 40 years old with aki withdrawing from etoh now as well
2-benzo overdose that has coverted into withdrawal with cryptic fevers to 42c
3-surgical abdominal disaster with fugemia on tpn no peripheral access
4-alcoholic cardiomyopathy Ef 10% ams transferred for aspiration hypo ventilating from benzo od given for withdrawal

You think you can create algorithms to account for each of these scenarios that a midlevel is going to follow? Do you think the midlevel is going to know about benzo dose reduction in low output chf (or better yet not using benzos), how to manage fungemia line sepsis in other no alternate access (no ID here btw), how to work up cryptic fever etc? If CCM consisted of IVF + abx next patient then it wouldn't demand extra training.

1. Give colloids, preferably prbc then albumin.
2. Give benzos.
3. Caspo. Get a new IV. Have surgeons wash out.
4. Treat aspiration. Give benzos carefully. Good thing they’re in an ICU.

Need some more algorithms?

 

[SXMMD]

I think we are missing the point. Mid levels do NOT have the expertise to take care of even routine hospitalized patients. They do NOT have the expertise to take care of undifferentiated patients in the ER or primary care clinic. They do NOT have the expertise to manage psychiatric illness. They do NOT have the expertise to manage anesthesia.

Yet here we are.

I am a hospitalist. I respect and rely on your expertise because I have some modicum of intellectual humility. The forces at work here have none. Why do you think your expertise makes you impervious to current trends when the rest of ours didn’t?

Anti-intellectualism in America is making huge gains. Spoiler, it’s coming for you too.

 

[bronx43]

People really need to realize that the medical-industrial complex is not about healthcare. Do you really think that those in political power look at the industry and think "what can we do to improve the lives of sick people?"
Lol, no. It's all about job creation. The parabolic rise of the administrators and other paper pushers in healthcare isn't a bug... it's a feature. Healthcare as a whole is literally a state-owned enterprise with a very specific political and economic agenda. Since the postwar era of the past 70 years, the US is increasingly relying on service industries to power the consumption economy that we've all enjoyed. And healthcare is a major driver of this growth paradigm.

So, yes. When it comes down to it, any benefits that were enjoyed by docs of old will be tossed aside for the "greater good" in order to allow more non-docs to suckle on the teat of the healthcare cow.

 

[CCM-MD]

1. Give colloids, preferably prbc then albumin.
2. Give benzos.
3. Caspo. Get a new IV. Have surgeons wash out.
4. Treat aspiration. Give benzos carefully. Good thing they’re in an ICU.

Need some more algorithms?

Lol?
What’s your background again?

 

[blue.jay]

Let me give you an example of a few people in my community icu that aren’t COVID:
1-ugib esld hard drinker 40 years old with aki withdrawing from etoh now as well
2-benzo overdose that has coverted into withdrawal with cryptic fevers to 42c
3-surgical abdominal disaster with fugemia on tpn no peripheral access
4-alcoholic cardiomyopathy Ef 10% ams transferred for aspiration hypo ventilating from benzo od given for withdrawal

You think you can create algorithms to account for each of these scenarios that a midlevel is going to follow? Do you think the midlevel is going to know about benzo dose reduction in low output chf (or better yet not using benzos), how to manage fungemia line sepsis in other no alternate access (no ID here btw), how to work up cryptic fever etc? If CCM consisted of IVF + abx next patient then it wouldn't demand extra training.

Very good examples. I agree there is no algorithm when handling very sick patients. These patients can be very sick and everyone knows only a doctor with extensive experience and knowledge should be handling such patients.

But we the know that private equity companies like sound/team health, hospital giants will try to save $$$ where it's more expensive. They know midlevels can't replace MDs in ICU/ER setting but what they are doing is having a MD suck up the liability and staff a busy unit ED/ICU with more midlevels instead of giving another physician. Even SCCM advocates for anesthesia ACT like model. Physician is the captain of the ship but these days it seems there is too much on your plate with various nursing and midlevel politics where I just see more burnout happening in employment model. I don't think there are many private practice ICU groups these days where we have a say in how things are done.

The main issue is the same for all hospital based specialities without a patient base like EM/ICU/anesthesia/hospitalist. We are seen as extra expense and the employers are pushing midlevels for roles which they aren't trained to do.

 

[Señor S]

eICU is another major complicating factor here. Even if the APPs recognize that they're in over their heads (which their culture somewhat trains them not to do) they can teleconference some guy at Emory (or wherever) who can help them "think about problems."

And as others have said, I don't see how APPs are any more qualified to work in emergency rooms or primary care offices. I'd view those as even less appropriate settings, since there (at least in theory) the well-trained eye can spot impending disasters and stop them before they start. Ultimately I don't view any of the policies related to APPs as being driven by anything resembling logic; it's politics and money all the way down. Even if we maintain a requirement for some form of in-person physician supervision there are plenty of unscrupulous baby-boomer docs who will just hire 2 NPs instead of 1 MD and pocket the salary difference for themselves.

 

[deleted941485]

People really need to realize that the medical-industrial complex is not about healthcare. Do you really think that those in political power look at the industry and think "what can we do to improve the lives of sick people?"
Lol, no. It's all about job creation. The parabolic rise of the administrators and other paper pushers in healthcare isn't a bug... it's a feature. Healthcare as a whole is literally a state-owned enterprise with a very specific political and economic agenda. Since the postwar era of the past 70 years, the US is increasingly relying on service industries to power the consumption economy that we've all enjoyed. And healthcare is a major driver of this growth paradigm.

So, yes. When it comes down to it, any benefits that were enjoyed by docs of old will be tossed aside for the "greater good" in order to allow more non-docs to suckle on the teat of the healthcare cow.

The way can create jobs in HC is basically take an attending job and give it to 3 MLPs!! Yay America!!

 

[the argus]

Maybe I'm biased by my own experiences, but I have not seen midlevels used in the ICU the same way that they are in the ED or general wards.

In the ED or general wards, they are increasing the number of patients being covered by a single physician, maybe by up to 40%. They essentially manage the patient by themselves and then the physician comes in and signs off on their work. I'm not trying to be offensive to anyone, but the reality is that the average ED or gen med patient is much less complex than the average ICU patient.

There have been midlevels in every ICU I have ever worked in (more than a handful between just as many hospitals) and I have never seen them utilized this way. They have never increased the total number of patients that a single intensivist covers.

 

[bronx43]

Maybe I'm biased by my own experiences, but I have not seen midlevels used in the ICU the same way that they are in the ED or general wards.

In the ED or general wards, they are increasing the number of patients being covered by a single physician, maybe by up to 40%. They essentially manage the patient by themselves and then the physician comes in and signs off on their work. I'm not trying to be offensive to anyone, but the reality is that the average ED or gen med patient is much less complex than the average ICU patient.

There have been midlevels in every ICU I have ever worked in (more than a handful between just as many hospitals) and I have never seen them utilized this way. They have never increased the total number of patients that a single intensivist covers.

So then where do their salaries come from?

 

[the argus]

So then where do their salaries come from?

Well these hospitals include academic centers, large private city hospitals, and smaller private community hospitals, and none of them have been the profit-only patient-care-be-damned hellscapes that many of the posters in this thread seem to work at...

But overall I think many of these places have found that having a midlevel or 2 around that can independently bill for critical care actually increases revenue as they bill for things that would otherwise just be managed by a resident/fellow without the attending and therefore just be lost revenue.

 

[CCM-MD]

Well these hospitals include academic centers, large private city hospitals, and smaller private community hospitals, and none of them have been the profit-only patient-care-be-damned hellscapes that many of the posters in this thread seem to work at...

But overall I think many of these places have found that having a midlevel or 2 around that can independently bill for critical care actually increases revenue as they bill for things that would otherwise just be managed by a resident/fellow without the attending and therefore just be lost revenue.

Thats how it starts. Give it some time and they will find some corners to cut to make money. Medicine is a business in the country.

 

[wamcp]

Thats how it starts. Give it some time and they will find some corners to cut to make money. Medicine is a business in the country.

How does admin sleep at night hiring noctors into the unit.

 

[deleted941485]

How does admin sleep at night hiring noctors into the unit.

Simple as long as its not them and they get a bonus they are okay with it. MBAs ruin every industry they touch.

 

[CCM-MD]

How does admin sleep at night hiring noctors into the unit.

Anyone in CCM: make your money now while things are hot, invest it well, and make sure you have an exit strategy because to me the future looks bleak.

 

[chessknt]

Jesus I hope nobody who actually likes CCM reads this **** and decides to do something else. Oh no NPs work in ICUs THE END IS NEAR WE ARE ALL BEING REPLACED PANIKKKK

 

[Nespresso]

NPs essentially resident/fellow roles in icu. Who needs an MD internist/intensivist when you can give 3 NP’s access to an uptodate account and certify them in line placements?

 

[chessknt]

NPs essentially resident/fellow roles in icu. Who needs an MD internist/intensivist when you can give 3 NP’s access to an uptodate account and certify them in line placements?

Yep it’s over might as well go work at Burger King. There’s definitely thousands of competent mid levels hanging around just lying in wait to steal icu work

 

[WheezyBaby]

Maybe I'm biased by my own experiences, but I have not seen midlevels used in the ICU the same way that they are in the ED or general wards.

In the ED or general wards, they are increasing the number of patients being covered by a single physician, maybe by up to 40%. They essentially manage the patient by themselves and then the physician comes in and signs off on their work. I'm not trying to be offensive to anyone, but the reality is that the average ED or gen med patient is much less complex than the average ICU patient.

There have been midlevels in every ICU I have ever worked in (more than a handful between just as many hospitals) and I have never seen them utilized this way. They have never increased the total number of patients that a single intensivist covers.

I've seen NP solo in house / MD home coverage at a community hospital. From a business of medicine standpoint, a provider who is cheaper, bills at a comparable rate, over tests, and over consults is going to be appealing so long as significant harm is not easily demonstrated ($$$). Patient care (be it in the icu, ward, ED, outpatient setting, etc) is complex and outcomes can be difficult to tangibly tie to care delivered in absence of robust studies. Given the above, I don't think it's surprising we've seen an expansion of APP practice, particularly in combination with APP organizations pushing this expansion of practice and a rapid surge in APP supply. As far as the differences in motivation for profit between a "for profit" and "not for profit" institution, they're not necessarily particularly different

 

[blue.jay]

Most (or almost everywhere) places are moving towards a model of APP night coverage (+/- eICU) with physician rounding during the day time (with APP). Though midlevels are not directly replacing physicians in the ICU there is no doubt they are putting pressure on the job market. Units which were staffed with 2 intensivists now can manage with 1 doc and APPs. I'm guessing this will saturate job markets for new fellows hoping to settle down in metro areas or other desirable locations.
No doubt there will always be a demand for high paying jobs in undesirable or rural locations.

 

[The kitchen sink]

I think the argument about complexity is a little bit overblown. The name of the game these days seems to be “how low can we set the bar in medicine” and I suspect deaths in critically ill patients will be blamed on critical illness rather than mid level incompetence as they surge in your field.

i agree.
do these pts need a true intensivist (md/do)? - well duh

does anyone in admin care?
- no

it’s a race to the bottom, and i think trends are extremely clear in this regard, as hospitals hire more and more cheap labor (midlevels), and increase their profit, they won’t give a hoot about the quality of care like we do. A few pt deaths and malpractice suits won’t even be enough to offset the amount of profit they will be making. The writings on the wall in my opinion.

it’ll take a massive mobilization of the physician cohort to either unionize, or centralize in some way, lobby/legislatation to prevent this, which by our track record won’t happen

we can just hope that just as the pendulum is swinging towards the extremes we are seeing in medicine now that maybe it’ll swing back….. however unlikely that may be