Nurse practitioners independent prescribing?

[Suit]

There may be some good NPs out there but ultimately this hurts patients the most. I recently saw an NP at a walk in and she referred me to a podiatrist. No, I will not let a podiatrist cut my leg open. I called the nearest ortho walk in clinic.

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[Kazaki]

How did doctors come to this?
Competing with apes for a job. Shame really.

 

[username456789]

How did doctors come to this?
Competing with apes for a job. Shame really.

First, you observe the apes in the wild, noting their simple motor skills.

Then you train the apes to do basic tasks like carve tools from rock or bone.

Then you are suddenly surprised when the apes use those tools to bash your skull in.

 

[TheFutureFatMan]

Because you're using an np the right way. Most nps push for more and more scope of practice. In the ED, they get mad if they're not seeing complicated patients. In anesthesia, they're demanding to do lines, epidurals, blocks, etc. which they shouldn't be doing. They are claiming equivalence between their education and yours. And yet surgery is different from medicine. Midlevels are not clamoring to do surgery yet. But I've read rumors about nps gearing up to do routine operations in the uk although I'm not sure about the veracity. Can you imagine having to fix a patient after they were mismanaged by a surgical np operating in the OR? This kind of thing happens on a regular basis in the ED where someone was sent home by a midlevel who didn't recognize what was going on and they come in with the pathology much farther along the course.

I don't want to take responsibility for someone else's actions unless I choose to do so like an academic attending does for a resident. With greater production pressures, there will be less oversight and more autonomy, and yet the physician will be required to use their license to shield the midlevel. So the midlevels get to play doctor and risk very little while the physician's name is on the chart. You can get through more patients and earn a little more money but is it worth the risk? Not if the extra money is going into the pockets of the administrators.

Also I've heard nps on the surgical team refuse to take a consult from a medical student in an academic institution. First of all, the patient needs a surgeon, not an np and the medical student wasn't consulting them. Second, it's a freaking academic institution where the goal is to teach, not to belittle trainees. That soured me greatly on their presence in academic institutions.

I know there are lots of NP's that are pushing to assist, same with PA's. There's also the fantastic "First Assist" certification that nurses can get. The surgeons I shadow all laugh, and they say that ANP's are fine, right until the crap hits the proverbial fan, then you really find yourself wanting an actual surgeon across from you. But I'm #notadoctor so who the hell knows.

 

[TheFutureFatMan]

... What's your beef with podiatrists? Some are damn good. A lot of our local orthos don't even take feet injuries, they go straight to podiatry, even surgical cases.

There may be some good NPs out there but ultimately this hurts patients the most. I recently saw an NP at a walk in and she referred me to a podiatrist. No, I will not let a podiatrist cut my leg open. I called the nearest ortho walk in clinic.

 

[Suit]

... What's your beef with podiatrists? Some are damn good. A lot of our local orthos don't even take feet injuries, they go straight to podiatry, even surgical cases.

No beef. Just don't feel comfortable with letting someone with training that probably required a 22 mcat for admission operating on me when an ankle fellowship trained ortho can do the same surgery. Podiatrists need to stop encroaching on ortho territory...

 

[VA Hopeful Dr]

No beef. Just don't feel comfortable with letting someone with training that probably required a 22 mcat for admission operating on me when an ankle fellowship trained ortho can do the same surgery. Podiatrists need to stop encroaching on ortho territory...

My city of 200,000 has 2 ankle-trained ortho guys and neither will do anything below the ankle. Anything on the actual foot goes to podiatry.

 

[Ho0v-man]

Wow. I check back after one day and we're calling mid levels apes and putting down board certified podiatrists based on their suspected MCAT scores.

Gee, I wonder why there's national organizations trying to get rid of doctors any way they can...


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[FiveOClock]

Wow. I check back after one day and we're calling mid levels apes and putting down board certified podiatrists based on their suspected MCAT scores.

Gee, I wonder why there's national organizations trying to get rid of doctors any way they can...


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They jelly.

 

[Psai]

I know there are lots of NP's that are pushing to assist, same with PA's. There's also the fantastic "First Assist" certification that nurses can get. The surgeons I shadow all laugh, and they say that ANP's are fine, right until the crap hits the proverbial fan, then you really find yourself wanting an actual surgeon across from you. But I'm #notadoctor so who the hell knows.

First assists are RNs, not NPs from what I know. They are advanced practice nurses of course, like every other nurse out there.

 

[criticalelement]

This is a topic that is covered ad nauseum on this site. There are countless threads about exactly this question.

Yes, there is a wide variety of clinical training. Yes, some of them on online, which, in my opinion, is a travesty. However, APNs do require clinical exposure as part of their training. But, there is poor oversight and these experiences can be of variable quality, which is also unacceptable to me.

As far as individual practice rights, this varies state-by-state. In some states, there is no independent practice. In some states, there is full practice right after graduation (which is dangerous, I feel). In other states, the APN is required to work in a supervised setting for several years prior to applying for independent privileges. I happen to feel that the latter is a good compromise for covering underserved areas. I have discussed this previously, you can look at my post history if you want, and this is why @coffee-doc felt the need to call me out.

I understand that you are not intending to bash them, but you did start yet another thread which will serve that purpose.

Now, cue the APN haters ...

HIre a P.A. you quack. That is why they were invented. You will never get me on board with the NP movement. NEVER>

 

[username456789]

First assists are RNs, not NPs from what I know. They are advanced practice nurses of course, like every other nurse out there.

No, RNs do not act as first assists. NPs do sometimes.

 

[criticalelement]

I am the guy who says supervised APNs are an important part of the healthcare team. However, I say this mostly in regards to expanded prescription rights, not independent practice.
.

You are saying give them independent practice rights because you are too lazy or busy to write them yourself.. Are you ***ing kidding me?

 

[FiveOClock]

I think we need to expand the current scope of NP practice to RNs. The current scope of RN practice should be expanded to medical assistants.

 

[ProfMD]

HIre a P.A. you quack. That is why they were invented. You will never get me on board with the NP movement. NEVER>

You are saying give them independent practice rights because you are too lazy or busy to write them yourself.. Are you ***ing kidding me?

Thank you for your mature and reasoned contribution to this conversation.

I have an APN who writes prescriptions and orders while the resident and I are operating. My argument in this regard has to do with allowing APNs to prescribe narcotics in a supervised setting. Totally different from independent practice rights.

As for my APN, she was with the division before I started. If I were to hire someone new, I would consider APNs and PAs for the position.

 

[ProfMD]

No, RNs do not act as first assists. NPs do sometimes.

RNs can get additional training and certification as first assistants.

PAs can also assist in surgery. I know of no APNs that first assist.

 

[exsanguination]

What is it with people and APNs on this site? I feel like it is middle school, where you really like someone, but you can't admit it to your friends, so you feel like you need to make fun of them instead. Threads like this pop up fairly regularly. Then some people find a way to bash APNs in threads that have nothing to do with APNs.

I can speak from experience with my APN. I have been working with her for 5 years. She has been an APN for 10 years. She handles the floor work, freeing the resident up to operate - this is good for the resident. It would help me, the resident, and the patient if she could write for all medications, including narcotics. For the most part, these are meds that I ask her to write for or are recommended by a consulting service. With the limited scope of medications we use on my service, I can almost guarantee that she knows more about the dosing, indications, contraindications, and adverse reactions than the interns who started last week.

I realize this is heresy to most of you. If you feel the need to keep bashing APNs to make yourself feel superior, go right ahead. But realize that, for the most part, APNs are not the enemy. While you may not agree with what national nursing organizations are pushing for (I certainly don't agree with it all), there are individual APNs who are helpful in caring for patients as part of the team. As you progress in your career, you will probably even meet some.

The healthcare system would not collapse without them, but it would slow down. And, on surgical services like mine with limited resident resources, the residents would have to take time out of the OR to manage floor work, discharges, ED admits, etc.

With all due respect, your situation is not threatened by your NP/PA - sorry your argument, while nice, doesn't hold any weight.

No APN is ever going to be trained to operate independently. It's just not going to happen. Whereas for the entirely clinical specialties, or office based specialties, those are easy targets.

This is just apples and oranges with your example vs. what's at stake

 

[psychMDhopefully]

How did doctors come to this?
Competing with apes for a job. Shame really.

Dramatic difference in culture. Most physicians are extremely liberal, cowardly, and I think most of them feel guilty for being born privileged, so they readily accept the everybody is equal Bernie Sanders philosophy. As someone who switched from nursing to medicine I can tell you the culture is completely different for nurses. Medical students are taught " nurses are great, they are equal, this is a "team" sport". Nursing students are taught doctor are a bunch of stuck up, over educated, socially ******ed, elitist, and NPs=MDs. Nurses aggressively push legislation and are vocal about how they are equal to doctors, while doctors cower in the corner not saying anything for fear of not appearing PC. I've honestly lost a lot of respect for physicians after starting this process.

 

[Psai]

No, RNs do not act as first assists. NPs do sometimes.

Proof? My post is based on what was told to me by surgical nps.

 

[giantswing]

Dramatic difference in culture. Most physicians are extremely liberal, cowardly, and I think most of them feel guilty for being born privileged, so they readily accept the everybody is equal Bernie Sanders philosophy. As someone who switched from nursing to medicine I can tell you the culture is completely different for nurses. Medical students are taught " nurses are great, they are equal, this is a "team" sport". Nursing students are taught doctor are a bunch of stuck up, over educated, socially ******ed, elitist, and NPs=MDs. Nurses aggressively push legislation and are vocal about how they are equal to doctors, while doctors cower in the corner not saying anything for fear of not appearing PC. I've honestly lost a lot of respect for physicians after starting this process.

Cowardly? Lost respect? Go back to nursing then.
Doctors being vocal about nurses lack of education would be as about effective as Donald trump making fun of poor people for choosing to be poor. Just how it is. We'll have our own by not, you know, killing people.

 

[giantswing]

No, RNs do not act as first assists. NPs do sometimes.

They do at several hospitals I've been at

 

[Pharmohaulic]

I know there are lots of NP's that are pushing to assist, same with PA's. There's also the fantastic "First Assist" certification that nurses can get. The surgeons I shadow all laugh, and they say that ANP's are fine, right until the crap hits the proverbial fan, then you really find yourself wanting an actual surgeon across from you. But I'm #notadoctor so who the hell knows.

Here's my thing, if nurses (and again, I like nurses and am not bashing them), but if they are so concerned with touting that nursing is a separate field distinct from medicine and that they are just as an important role, they why are they continuously trying to redefine their scope of practice to be more like physicians?

Like what happened to good old fashioned BEDSIDE nursing where nurses had the desire and compassion to fulfill that role... Now everyone's going into nursing with the ultimate goal of bypassing bedside nursing as quickly as they can to move on to be a nurse practitioner and gloat about how superior they are to everyone else.

I've seen this behavior with so many (but not all) nurse practitioners, heck even some regular RN's who for some reason feel the need to put down every other Healthcare professional (not just physicians) they work with, and think they can do their job better. I've seen them have this attitude with social workers, occupational therapists, respiratory therapists, physicians, PA's etc.

For instance I have one friend who is a nurse (RN) that routinely tells me about PA's, "Yeah I really don't know what the point of them is. They don't know much of anything and I can pretty much do exactly what they do with my associates." and for the clinical social worker on her floor, she states, "Yeah and like honestly what the heck is the point of therapy and all the stupid advocating... It's pointless and I can do all of that without an MSW."

 

[sonofva]

How dare you knowledge shame the NPs. If they identify as competent prescribers, who are you (or any governing board) to tell them otherwise???

Check your privilege.

"I'm PC MD."


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[TheFutureFatMan]

No, RNs do not act as first assists. NPs do sometimes.

https://www.aorn.org/guidelines/clinical-resources/rn-first-assistant-resources

 

[cbrons]

the war was lost once the MDs/DOs accepted the term "provider"

Yep

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[cbrons]

You are saying give them independent practice rights because you are too lazy or busy to write them yourself.. Are you ***ing kidding me?

Hes too busy cashing his checks to care. He makes a lot off their work and whether he ruins the profession for the next generation is not really relevant. He said as much himself in another thread.

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[ProfMD]

Hes too busy cashing his checks to care. He makes a lot off their work and whether he ruins the profession for the next generation is not really relevant. He said as much himself in another thread.

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Actually, the post you are referring to was a tongue-in-cheek rebuttal to a post by someone else.

I am actually not making a lot of money off my APNs work. I really do not make anything off the work she does. Mostly her work allows the resident to operate more.

I am in academics anyway, I am not making bank off of anyone.

Your post is another fine example of the contributions that people make to SDN.

 

[Kazaki]

Dramatic difference in culture. Most physicians are extremely liberal, cowardly, and I think most of them feel guilty for being born privileged, so they readily accept the everybody is equal Bernie Sanders philosophy. As someone who switched from nursing to medicine I can tell you the culture is completely different for nurses. Medical students are taught " nurses are great, they are equal, this is a "team" sport". Nursing students are taught doctor are a bunch of stuck up, over educated, socially ******ed, elitist, and NPs=MDs. Nurses aggressively push legislation and are vocal about how they are equal to doctors, while doctors cower in the corner not saying anything for fear of not appearing PC. I've honestly lost a lot of respect for physicians after starting this process.

As your username suggests, you will always dream of becoming a doctor

 

[username456789]

As your username suggests, you will always dream of becoming a doctor

Say what you want, but he/she is not really wrong.

 

[psychMDhopefully]

As your username suggests, you will always dream of becoming a doctor

Sooo no counter argument=random insult?

 

[cbrons]

No APN is ever going to be trained to operate independently.

I bet in 5 years you won't believe this statement.

 

[giantswing]

Sooo no counter argument=random insult?

It'll fall into place why you can't fight back at two in the morning because you're just too tired and it's just not worth it. Nurses will be the band of your existence and you will curse their named. And there will be nothing you can do about it.

 

[exsanguination]

I bet in 5 years you won't believe this statement.

You know, the more I think about this, you are correct.

Now, I'm a "dumb ER doctor," (well, resident ), but based on my surgical experience, and talking to our surgery residents (some of whom were my friends from medical school), I strongly believe you could teach an APN to do a lap appy over the course of 3-4 years in their career as a surgical nurse pracitioner. Or PA, depending on your flavor of the day.

It would almost work like anesthesia does now (hell, even how some orthopods do it these days), with the APN basically doing the entire case with the surgeon covering 2-3 rooms. Elective cholecystectomy and routine breast stuff, same thing.

Again, I know this will get some surgeon in here to come huff and puff about how I don't know anything, and they're right, but the only opinion that matters in this conversation is the MBA's in the C-suite. He does not give one lick about the slight increase in post-op complications or wound infections, as long as at the end of the day the increased volume and decreased salary for the APN nets him a good margin.

Though, as many in this thread mentioned, the attendings that sold out their young are the ones that created this problem, and will continue to push it forward. Doctors, particularly surgeons for some reason, are fiercely independent. And surgeons almost have to be hostile to each other, because that's the competition a few blocks down that's looking for the same pathology/referrals you are!

The situation is dire, and won't change anytime soon.

I'd still advise any medical student to not go into medicine unless you think you can become a proceduralist of some kind.

 

[W19]

AAFP Decries VA Plan to Expand Nurses' Scope of Practice

http://www.aafp.org/news/government-medicine/20160715valetter.html?cmpid=em_56559837_B1

 

[username456789]

AAFP Decries VA Plan to Expand Nurses' Scope of Practice

http://www.aafp.org/news/government-medicine/20160715valetter.html?cmpid=em_56559837_B1

Onc again, we shouldn't worry about this because ProfMD says this is all made up. And, like, lymphocyte totally did some medical consulting so he knows for a fact that NPs are not trying to steal anyone's piece of the pie.

Nothing to see here folks.

 

[username456789]

On a serious note, this is how it happens. You keep chipping away at different parts of the dam (or dike, if you prefer) until you find the weakest point and it finally gives way.

 

[Mansamusa]

On a serious note, this is how it happens. You keep chipping away at different parts of the dam (or dike, if you prefer) until you find the weakest point and it finally gives way.

There is a perfect storm of things occurring though. Like the comments on the AAFP article say, physicians caused this to occur by inactivity and focus on money.

Physicians are dropping medicare at higher rates.....what do you think will happen? We need specialists to see medicare patients, NPs will step in and offer to help. NPs don't need to chip because physicians are clearing the path to let them step in.

Primary care has a ton of issues and isn't financially worth it to those needing loans to pay for all of med school. Rather than address those issues, everyone just dropped primary care and scrambled for specialty positions. This left a nice gap for NPs to fill in.

Every time there is any challenge or issue, physicians scramble as far from the problem as they can rather than stand up for themselves or actually come up with plans. Physicians are all about self-preservation rather than establishing viable solutions to problems- it's surprising.

 

[giantswing]

There is a perfect storm of things occurring though. Like the comments on the AAFP article say, physicians caused this to occur by inactivity and focus on money.

Physicians are dropping medicare at higher rates.....what do you think will happen? We need specialists to see medicare patients, NPs will step in and offer to help. NPs don't need to chip because physicians are clearing the path to let them step in.

Primary care has a ton of issues and isn't financially worth it to those needing loans to pay for all of med school. Rather than address those issues, everyone just dropped primary care and scrambled for specialty positions. This left a nice gap for NPs to fill in.

Every time there is any challenge or issue, physicians scramble as far from the problem as they can rather than stand up for themselves or actually come up with plans. Physicians are all about self-preservation rather than establishing viable solutions to problems- it's surprising.

The self preservation instinct comes from years of call.

 

[ProfMD]

Onc again, we shouldn't worry about this because ProfMD says this is all made up. And, like, lymphocyte totally did some medical consulting so he knows for a fact that NPs are not trying to steal anyone's piece of the pie.

Nothing to see here folks.

1) I never said this was all made up.

2) I do not agree with the VA plan. The VA health system has problems that extend way beyond number of providers. Access will not be fixed by expanding APN roles.

Thanks for speaking for me, though. Even though you got it wrong, its nice to know that there are others that can speak for me until I get a chance to comment.

 

[username456789]

1) I never said this was all made up.

2) I do not agree with the VA plan. The VA health system has problems that extend way beyond number of providers. Access will not be fixed by expanding APN roles.

Thanks for speaking for me, though. Even though you got it wrong, its nice to know that there are others that can speak for me until I get a chance to comment.

I assume your NP wrote this post and you just signed off on it.

 

[username456789]

Again to be a little less of an ass, what none of us can figure out is how you cannot seemingly separate what you think NPs' roles should be with the inevitable encroachment that will occur beyond your control.

Didn't you ever read or see Jurassic Park? It's the same hubris that did John Hammond in. You don't bring dinosaurs [back] into our world and then get to say "but only if you behave!"

 

[giantswing]

I assume your NP wrote this post and you just signed off on it.

Sorry but lol...

 

[ProfMD]

I assume your NP wrote this post and you just signed off on it.

Again to be a little less of an ass, what none of us can figure out is how you cannot seemingly separate what you think NPs' roles should be with the inevitable encroachment that will occur beyond your control.

Didn't you ever read or see Jurassic Park? It's the same hubris that did John Hammond in. You don't bring dinosaurs [back] into our world and then get to say "but only if you behave!"

I don't, as a general rule, sign off on APN notes. I sign off on resident notes.

And, there are people who can figure out what I am saying. All I have said is that in limited circumstances (underserved areas) and with proper clinical training (years of supervised practice with a physician), I think APNs can play a role in primary care. I have also conceded that this will be a hard sell to physicians (too much autonomy for APNs) and nursing (not enough autonomy). There, this plan would never happen. Anything more than this, I would disagree with, such as the VA proposal. My point is, and always has been, that care by a properly trained APN is better than no care at all. I have also said, repeatedly, that I would fully support a physician taking these rural jobs over an APN. However, areas remain underserved because physicians do not want to work there. Another approach would be to incentivize physicians to take these jobs, which I would support over expansion of APN practice. I understand that there are those out there who will make the slippery slope argument. I just don't take as a reason not to try and help people who need medical care, and don't have it, to get medical care.

The only other expansion I have supported is allowing APNs in supervised practice to prescribe narcotics. This would help to streamline the care of patients whose overall healthcare is under the direction of a physician but at the same time allow the physician to do other things (for instance, in my situation, to operate).

So, you can be an ass all you want, level all the ad hominem attacks you want, but you (and others) still perpetually misrepresent my positions. But, if you need to denigrate me to enhance your own sense of self-worth, go right ahead.

 

[W19]

I don't, as a general rule, sign off on APN notes. I sign off on resident notes.

And, there are people who can figure out what I am saying. All I have said is that in limited circumstances (underserved areas) and with proper clinical training (years of supervised practice with a physician), I think APNs can play a role in primary care. I have also conceded that this will be a hard sell to physicians (too much autonomy for APNs) and nursing (not enough autonomy). There, this plan would never happen.

You keep using that 'underserved areas' argument when another poster already pointed out that NP don't go to 'underserved areas'... post #26.

 

[VA Hopeful Dr]

I don't, as a general rule, sign off on APN notes. I sign off on resident notes.

And, there are people who can figure out what I am saying. All I have said is that in limited circumstances (underserved areas) and with proper clinical training (years of supervised practice with a physician), I think APNs can play a role in primary care. I have also conceded that this will be a hard sell to physicians (too much autonomy for APNs) and nursing (not enough autonomy). There, this plan would never happen. Anything more than this, I would disagree with, such as the VA proposal. My point is, and always has been, that care by a properly trained APN is better than no care at all. I have also said, repeatedly, that I would fully support a physician taking these rural jobs over an APN. However, areas remain underserved because physicians do not want to work there. Another approach would be to incentivize physicians to take these jobs, which I would support over expansion of APN practice. I understand that there are those out there who will make the slippery slope argument. I just don't take as a reason not to try and help people who need medical care, and don't have it, to get medical care.

The only other expansion I have supported is allowing APNs in supervised practice to prescribe narcotics. This would help to streamline the care of patients whose overall healthcare is under the direction of a physician but at the same time allow the physician to do other things (for instance, in my situation, to operate).

So, you can be an ass all you want, level all the ad hominem attacks you want, but you (and others) still perpetually misrepresent my positions. But, if you need to denigrate me to enhance your own sense of self-worth, go right ahead.

You're making reasonable points, but it appears (and I could be wrong here) that you're approaching this in light of "how can NPs make my life easier" not "are these uses of NPs improving patient care".

Being in academics, you might not be affected by this as much as community docs but as patients are starting to pay more and more for their care they are starting to pay more attention. If I'm paying $2000 for you to operate on me (compared to a $100 copay 10 years ago), I expect a physician to round on me and do my post-op care. In July alone I have had 4 patients (I keep track of this sort of thing - many of us concierge people do) request I find them a new orthopedic surgeon because their now-previous group started using midlevels for follow-up visits.

I think writing for narcotics could be allowed with very stringent rules - no more than a 3 day supply. Period. You want your patients to have more than that, have your NP write up a script and bring it to your OR to sign. I think you can spare 15 seconds to sign your name (or a whole 5 minutes if you have to do it yourself on the EMR as some require it).

As has been pointed out, NPs don't want to move to middle-of-nowhere any more than doctors do. The only way to change that is to make it a requirement, and I can't support that (and I don't think you would either).

To address that NP care is better than no care - that is absolutely not true. On a basic level, given antibiotics for a cold is much worse than not getting care for that cold. On a slightly more advanced level, I direct you to the ALLHAT study. In case you're unfamiliar (and honestly I hope you are, your time is better spent on surgical literature than blood pressure studies), it shows that mortality increased compared to placebo when treating hypertension with alpha blockers. Not saying NPs are going to go around treating blood pressure with Flomax, but you get the idea.

Lastly (and I've saved this for last since I'm a bit displeased about it), I'm glad you think that NPs can do primary care. In fact, why don't I just let you surgeons make all the decisions about primary care's future. Honest to God man, who the hell do you think you are? You don't see us PCPs saying "oh just let NPs with enough experience do basic OR procedures". We have the sense to realize that we don't understand the intricacies of what you do (beyond the occasional "a monkey could be trained to operate" joke, which is as mentioned a joke). I'm sorry to see that you do not possess that same sense. Now with that out of the way, I actually wouldn't care if NPs got full autonomy tomorrow. I'm better than they are at my job. I know it and my patients know it. I actually get several new patients every month who come to me because their previous doctor is hiring midlevels and they only want to be seen by a physician. Plus, it would finally allow us to show that they are not as capable as we are (or as cost-effective).

 

[ProfMD]

You keep using that 'underserved areas' argument when another poster already pointed out that NP don't go to 'underserved areas'... post #26.

You're making reasonable points, but it appears (and I could be wrong here) that you're approaching this in light of "how can NPs make my life easier" not "are these uses of NPs improving patient care".

Being in academics, you might not be affected by this as much as community docs but as patients are starting to pay more and more for their care they are starting to pay more attention. If I'm paying $2000 for you to operate on me (compared to a $100 copay 10 years ago), I expect a physician to round on me and do my post-op care. In July alone I have had 4 patients (I keep track of this sort of thing - many of us concierge people do) request I find them a new orthopedic surgeon because their now-previous group started using midlevels for follow-up visits.

I think writing for narcotics could be allowed with very stringent rules - no more than a 3 day supply. Period. You want your patients to have more than that, have your NP write up a script and bring it to your OR to sign. I think you can spare 15 seconds to sign your name (or a whole 5 minutes if you have to do it yourself on the EMR as some require it).

As has been pointed out, NPs don't want to move to middle-of-nowhere any more than doctors do. The only way to change that is to make it a requirement, and I can't support that (and I don't think you would either).

To address that NP care is better than no care - that is absolutely not true. On a basic level, given antibiotics for a cold is much worse than not getting care for that cold. On a slightly more advanced level, I direct you to the ALLHAT study. In case you're unfamiliar (and honestly I hope you are, your time is better spent on surgical literature than blood pressure studies), it shows that mortality increased compared to placebo when treating hypertension with alpha blockers. Not saying NPs are going to go around treating blood pressure with Flomax, but you get the idea.

Lastly (and I've saved this for last since I'm a bit displeased about it), I'm glad you think that NPs can do primary care. In fact, why don't I just let you surgeons make all the decisions about primary care's future. Honest to God man, who the hell do you think you are? You don't see us PCPs saying "oh just let NPs with enough experience do basic OR procedures". We have the sense to realize that we don't understand the intricacies of what you do (beyond the occasional "a monkey could be trained to operate" joke, which is as mentioned a joke). I'm sorry to see that you do not possess that same sense. Now with that out of the way, I actually wouldn't care if NPs got full autonomy tomorrow. I'm better than they are at my job. I know it and my patients know it. I actually get several new patients every month who come to me because their previous doctor is hiring midlevels and they only want to be seen by a physician. Plus, it would finally allow us to show that they are not as capable as we are (or as cost-effective).

It's almost like you guys do not read what I write before responding. I will spell out my opinion (again) in case my writing is unclear. Please read it slowly to ensure comprehension before responding.

1) If APNs were to be given independent practice rights, I would absolutely want them to be required to work in underserved areas. Even before they were allowed this, I would want them to spend several years working with a physician who would then have to sign off on their competence. However, as I have stated many times, I realize that this sort of legislation would not fly for several reasons. Any other expansion of independent APN practice, I would not support. I have also stated that I would support physicians taking these jobs over APNs. I would absolutely support incentives to get physicians to take these jobs. If they did, they would not longer be underserved, and I would no longer support APN independence.

2) I respectfully disagree that no care is better than APN care. In my opinion, MD/DO > properly trained APN > nothing (insert as many '>' signs as you want). By properly trained, I mean those who finish APN school and then spend years in supervised practice with a physician. Then they can learn all about not giving antibiotics for a cold (and, seriously, you think physicians don't give antibiotics for viral illness?). Do I think APNs are an equivalent replacement for physicians? No. Do I think physicians are the gold standard for primary care and do a better job than APNs? Absolutely. I do, however, think that a properly trained APN is better than the no care that some people get now. I am sorry that I offended you. I hope I have made my opinion clear. You are better than an APN and I never meant to imply otherwise.

3) I am glad you called those orthopedic surgeons on their BS of not seeing their own postoperative patients. I round on my inpatients at least once a day, most often twice. On the inpatient side, my APN takes care of the floor work while I operate. That is, she enacts plans that I make on rounds - writes transfer orders, calls consults, discharges patients, etc. She also answers pages from the floor nurses while the resident and I are operating. She will see new consults while I am operating, but always runs them by me (or one of my partners). An attending then sees the patient after finishing in the OR. On the outpatient side, I see all my own postoperative follow-ups and new consults. There are a limited number of non-operative follow-ups that she sees and these patients know they are coming to see an APN. The only other time she sees clinic patients are if I get stuck in the OR with an emergency and have scheduled patients in clinic. Then the patients can either see her and leave or wait for me. Most choose to see her. They know her from the inpatient side anyway. So, this does improve patient care by expediting it. It also makes my life easier. The two goals are not mutually exclusive.

 

[Taddy Mason]

You keep using that 'underserved areas' argument when another poster already pointed out that NP don't go to 'underserved areas'... post #26.

No, post #26 offered an unfounded statement. I'm from one of the most rural parts of the country and outside of the 4 major cities mid-levels (especially NPs) out number physicians everywhere. Mid-levels are primarily the ones filling the void in these areas.

 

[W19]

No, post #26 offered an opinion, which is just that, an opinion. I'm from one of the most rural parts of the country and outside of the 4 major cities mid-levels (especially NPs) out number physicians everywhere. Mid-levels are primarily the ones filling the void in these areas.

his was an opinion and yours is fact since what you describe is happening everywhere in the country. We still have a shortage (or maldistribution) 50+ years after introducing that midlevel stuff. A lot of them are working as floor RN in south FL... I guess they are not too eager filling in the gap in FL panhandle.

 

[Taddy Mason]

his was an opinion and yours is fact since what you describe is happening everywhere in the country. We still have a shortage (or maldistribution) 50+ years after introducing that midlevel stuff. A lot of them are working as floor RN in south FL... I guess they are not too eager filling in the gap in FL panhandle.

Psai made a statement with nothing to back it up - not even anecdotal evidence. What I brought-up is true for my state and 4 other states in the region, which comprises one of the largest undeserved areas of the US.

Edit - A mid-level working as a floor RN makes no sense, not sure where you were going with that one.

 

[Slack3r]

I don't know what state you guys are in re: nurses prescribing narcs. I watched our NP prescribe #90 oxy with a refill yesterday.