RIP California PCPs

[aSagacious]

Bill Text - AB-890 Nurse practitioners: scope of practice: practice without standardized procedures.

"The bill would require the board, by regulation, to define minimum standards for a nurse practitioner to transition to practice without the routine presence of a physician and surgeon. The bill would authorize a nurse practitioner who meets certain education, experience, and certification requirements to perform, in certain settings or organizations, specified functions without standardized procedures, including ordering, performing, and interpreting diagnostic procedures, certifying disability, and prescribing, administering, dispensing, and furnishing controlled substances." etc etc

Who knows whether it'll pass but probably a matter of when, not if.

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[nimbus]

CRNAs have had independent practice rights in California since 2009 and it’s still mostly MD only anesthesia. The rare places CRNAs practice independently tend to be very remote or have a severely challenged payor mix. Speaking as a California anesthesiologist, I don’t think California PCPs have anything to worry about.

 

[commonwealthMD]

Nurses want to play doctor but don't want to study and go to MD school. The NPs I've worked with were pretentious and insufferable.

Askforaphysician.com

 

[deleted939704]

CRNAs have had independent practice rights in California since 2009 and it’s still mostly MD only anesthesia. The rare places CRNAs practice independently tend to be very remote or have a severely challenged payor mix. Speaking as a California anesthesiologist, I don’t think California PCPs have anything to worry about.

As someone interested in Gas/Pain, should I be worried about mid levels or is that overblown?

 

[commonwealthMD]

As someone interested in Gas/Pain, should I be worried about mid levels or is that overblown?

No one is safe from the degree mill mid levels. Soon you'll have NPs perfoming brain surgery to save the insurance companies a buck...

 

[nimbus]

As someone interested in Gas/Pain, should I be worried about mid levels or is that overblown?

I can only speak to California where the answer is no. For me it only comes up on SDN but never in real life.

 

[commonwealthMD]

I can only speak to California where the answer is no. For me it only comes up on SDN but never in real life.

SDN is an echochamber of negativity

 

[Goro]

I can only speak to California where the answer is no. For me it only comes up on SDN but never in real life.

I know a certain SDNer whose head will explode if he reads the OP.

 

[OnePunchBiopsy]

I mean, this is coming from a state that recognizes acupuncturists as PCP's. Pretty low bar if you ask me.

 

[nimbus]

I mean, this is coming from a state that recognizes acupuncturists as PCP's. Pretty low bar if you ask me.

And there are people including MDs and DOs who inject PRP and “stem cells” into every part of the body for large sums of money and dubious indications. Low bar indeed.

 

[Detective SnowBucket]

I've only just been accepted to med school. I've been studying and working towards this for a long time. No amount of physics, clinical-volunteering hours or MCAT prep has discouraged me from going into the field of medicine as much as this.

 

[Matthew9Thirtyfive]

I've only just been accepted to med school. I've been studying and working towards this for a long time. No amount of physics, clinical-volunteering hours or MCAT prep has discouraged me from going into the field of medicine as much as this.

Don’t be. Many of the attendings on here will assure you that stuff like this will not ruin your career. @VA Hopeful Dr has said many times that despite NPs and the like, he regularly has patients coming to him to see a real doctor.

 

[OnePunchBiopsy]

And there are people including MDs and DOs who inject PRP and “stem cells” into every part of the body for large sums of money and dubious indications. Low bar indeed.

Bro, that stuff works! Joe Rogan told me so on his podcast.

 

[Chemist0157]

Some SDNers might be surprised by real life. If you cannot market yourself as being better than an NP, you will not be able to market yourself against other physicians in more competitive areas.

The more I read here, the more I think some still in training somehow think that because they chose to go into medicine, they should be invulnerable to other forces that exist in other fields.

 

[nimbus]

Bro, that stuff works! Joe Rogan told me so on his podcast.

Joe Rogan is actually a smart and interesting guy. If he says it works, I believe him

 

[Splenda88]

 

[VA Hopeful Dr]

Some SDNers might be surprised by real life. If you cannot market yourself as being better than an NP, you will not be able to market yourself against other physicians in more competitive areas.

The more I read here, the more I think some still in training somehow think that because they chose to go into medicine, they should be invulnerable to other forces that exist in other fields.

I mean, it's reasonable true that many (most?) of us are pretty shielded from market forces.

 

[nimbus]

It’s not a red or blue issue. Lots of red states have already moved in the same direction. California is actually one of the holdouts.

State Practice Environment

It’s essential that NPs and policy makers have a clear understanding of how their state laws and regulations impact their practice. AANP’s interactive State Practice Environment map provides an overview of NP licensure for all 50 states, Washington, D.C. and U.S. territories. For details about the…

www.aanp.org

Edit: if this post seems irrelevant, mods removed the post to which I was replying.

 

[CoastalOT]

Nurses want to play doctor but don't want to study and go to MD school. The NPs I've worked with were pretentious and insufferable.

Askforaphysician.com

I am an outsider reading this thread, and I'm not sure that implying an entire profession is pretentious or insufferable is fair. Many of these comments seem not to be in the spirit of collaboration and respect that we are all called to in healthcare as interdisciplinary team members working together for patient care. It isn't the 1950s, the hierarchical model of providers is basically out the window these days, and there does seem to be some residue of it in these comments. I understand that you are students, and you feel you are being advocates for the profession you are taking on, but bashing members of other healthcare professions is not constructive.

It seems rather unseemly to me for future clinicians to be behaving this way.

 

[Pepe18]

I am an outsider reading this thread, and I'm not sure that implying an entire profession is pretentious or insufferable is fair. Many of these comments seem not to be in the spirit of collaboration and respect that we are all called to in healthcare as interdisciplinary team members working together for patient care. It isn't the 1950s, the hierarchical model of providers is basically out the window these days, and there does seem to be some residue of it in these comments. I understand that you are students, and you feel you are being advocates for the profession you are taking on, but bashing members of other healthcare professions is not constructive.

It seems rather unseemly to me for future clinicians to be behaving this way.

I agree that we should not paint any professions with broad strokes (like “heart if nurse, brain of doctor” campaigns that try to paints nurses as saints and doctors as heartless).

However, I oppose NP independent practice because I support interdisciplinary teams. NPs are trained for a limited scope of practice that involves collaborating with physicians. In exchange for faster schooling and less training, they get a limited picture of medicine. NPs are good at managing the things they were explicitly trained to manage, but patients’ conditions aren’t in a bubble. If you are only trained to look at one thing, there is so much you will miss. That is why it is important for a physician to be around to see the bigger picture.

My grandpa is on dialysis because of the mistake of a NP. Dialysis will significantly lower his life expectancy and quality of life. I wouldn’t trust a MD intern to manage complex issues, let alone a NP. Collaboration should exist for a reason.

MDs starting as attendings, even after over a decade of training, are terrified because there is so much to know. NPs, with a fifth of the training, should be terrified. It’s concerning that they aren’t and that they would prefer to “wing it” by learning on the job and practicing independently

 

[Chemist0157]

I mean, it's reasonable true that many (most?) of us are pretty shielded from market forces.

You're not wrong. A benefit of the specialized training in a high demand field is job security for instance. However, I do not think that precludes total protection from anyone trying to cut in on one's business. Independent NPs should not be able to compete with an already successful MD practice. If the NPs are moving into areas where there is provider scarcity then I cannot really complain? Either docs have chosen not to work in that area, or there are no docs available to work in that area.

The powers that be are under pressure to try to fulfill a need. I am all for having MDs fulfill that role, but if they are not moving to those areas, if they are not going into primary care, if programs/govt are not incentivizing trainees to do the aforementioned, then having NPs practice independently to provide some degree of care seems like a logical conclusion. I don't like it, but it makes sense.

Most of that was not directed specifically to you, just some of my other thoughts.

 

[Splenda88]

I am an outsider reading this thread, and I'm not sure that implying an entire profession is pretentious or insufferable is fair. Many of these comments seem not to be in the spirit of collaboration and respect that we are all called to in healthcare as interdisciplinary team members working together for patient care. It isn't the 1950s, the hierarchical model of providers is basically out the window these days, and there does seem to be some residue of it in these comments. I understand that you are students, and you feel you are being advocates for the profession you are taking on, but bashing members of other healthcare professions is not constructive.

It seems rather unseemly to me for future clinicians to be behaving this way.

It also would be nice if you can tell your nurses colleagues to stop bashing physicians

 

[Splenda88]

You're not wrong. A benefit of the specialized training in a high demand field is job security for instance. However, I do not think that precludes total protection from anyone trying to cut in on one's business. Independent NPs should not be able to compete with an already successful MD practice. If the NPs are moving into areas where there is provider scarcity then I cannot really complain? Either docs have chosen not to work in that area, or there are no docs available to work in that area.

The powers that be are under pressure to try to fulfill a need. I am all for having MDs fulfill that role, but if they are not moving to those areas, if they are not going into primary care, if programs/govt are not incentivizing trainees to do the aforementioned, then having NPs practice independently to provide some degree of care seems like a logical conclusion. I don't like it, but it makes sense.

Most of that was not directed specifically to you, just some of my other thoughts.

The issue is that all these NP are not going to places where they are needed (aka rural America). They also want to enjoy what America cities and suburbia have to offered.

 

[Chemist0157]

The issue is that all these NP are not going to places where they are needed (aka rural America). They also want to enjoy what America cities and suburbia have to offered.

If I were California, I would add a stipulation that the NPs have to demonstrate scarcity of the area or a known area of scarcity where they want to independently practice for the state to let them practice in that area.

I expect NPs to have a hard time just setting up shop in an area where physicians are already practicing. Maybe they come under the wings of a practice, but that would be unexpected as why would a private physician practice do that. Maybe under a hospital system, but they would have to respect liability issues. I expect this to have a lot of practical issues.

 

[CoastalOT]

It also would be nice if you can tell your nurses colleagues to stop bashing physicians

Please see comments on collaboration. Perhaps I am a bit too idealistic, I look at doctors, PAs, NPs, etc as my allies as we work to help our patients get better. We aren't in a competition with one another. There are some legitimate concerns that can be raised in an appropriate manner, however, some of these comments seem to be rather antagonistic, and motivated by insecurity.

Would you attach your names to these comments? If not, you probably should re-evaluate the comment. Your comments reflect on your profession. If I do encounter nurses "bashing" doctors, I would certainly say the same thing. This is all, quite frankly, unbecoming behavior for healthcare professionals.

 

[67552931811]

I am an outsider reading this thread, and I'm not sure that implying an entire profession is pretentious or insufferable is fair. Many of these comments seem not to be in the spirit of collaboration and respect that we are all called to in healthcare as interdisciplinary team members working together for patient care. It isn't the 1950s, the hierarchical model of providers is basically out the window these days, and there does seem to be some residue of it in these comments. I understand that you are students, and you feel you are being advocates for the profession you are taking on, but bashing members of other healthcare professions is not constructive.

It seems rather unseemly to me for future clinicians to be behaving this way.

Stop calling physicians ‘providers’. I didn’t go to provider school and there 100% is a hierarchy. Until you can go through the rigorous schooling and training physicians did, passed the insane exams and boards physicians did, make the independent decisions physicians make and then take all the legal liability there 100% will be a hierarchy. Your viewpoint is myopic and naive and not representative of the real world.

 

[deleted936470]

I am an outsider reading this thread, and I'm not sure that implying an entire profession is pretentious or insufferable is fair. Many of these comments seem not to be in the spirit of collaboration and respect that we are all called to in healthcare as interdisciplinary team members working together for patient care. It isn't the 1950s, the hierarchical model of providers is basically out the window these days, and there does seem to be some residue of it in these comments. I understand that you are students, and you feel you are being advocates for the profession you are taking on, but bashing members of other healthcare professions is not constructive.

It seems rather unseemly to me for future clinicians to be behaving this way.

The bolded is untrue & to the rest of this message, whatever. My state allows independent practice for NPs and I'll tell you that the ones I work with "consult" physicians assigned the same shift only to have that same doc work up the entire patient. Then the NP is surprisepikachu.jpeg when sometimes the physician invoices them. The NPs that work here only want to take full responsibility when things are going right... not to mention how many times I've heard these individuals introduce themselves as a doctor to the patient, I can see why attendings here choose not to collaborate.

 

[studentxx8800]

I am an outsider reading this thread, and I'm not sure that implying an entire profession is pretentious or insufferable is fair. Many of these comments seem not to be in the spirit of collaboration and respect that we are all called to in healthcare as interdisciplinary team members working together for patient care. It isn't the 1950s, the hierarchical model of providers is basically out the window these days, and there does seem to be some residue of it in these comments. I understand that you are students, and you feel you are being advocates for the profession you are taking on, but bashing members of other healthcare professions is not constructive.

It seems rather unseemly to me for future clinicians to be behaving this way.

Have you work in real life clinical setting yet? There is a hierarchy in every clinical setting. I have never seen a nurse/NP/PA giving orders to doctors but the other way around is the norm. Now, of course, we act politely as we should and “request” that the nurse or mid levels do something for us and say thank you but you fooling yourself if you think they are not orders. Doctors are the leaders of the team and as all good leaders should, we always aim to listen to team members perspective but that does not mean everyone is on equal footing when it comes to decision making for patient care

 

[Splenda88]

Stop calling physicians ‘providers’. I didn’t go to provider school and there 100% is a hierarchy. Until you can go through the rigorous schooling and training physicians did, passed the insane exams and boards physicians did, make the independent decisions physicians make and then take all the legal liability there 100% will be a hierarchy. Your viewpoint is myopic and naive and not representative of the real world.

Everyone likes to use the word collaboration but when things go wrong, all the fingers seem to be pointing in one direction...

 

[deleted480308]

Please see comments on collaboration. Perhaps I am a bit too idealistic, I look at doctors, PAs, NPs, etc as my allies as we work to help our patients get better. We aren't in a competition with one another. There are some legitimate concerns that can be raised in an appropriate manner, however, some of these comments seem to be rather antagonistic, and motivated by insecurity.

Would you attach your names to these comments? If not, you probably should re-evaluate the comment. Your comments reflect on your profession. If I do encounter nurses "bashing" doctors, I would certainly say the same thing. This is all, quite frankly, unbecoming behavior for healthcare professionals.

There is no collaboration. There is supervision and there is independent practice. Collaboration is a term used to have the safety of supervision with the ego of independence

 

[sab3156]

It isn't the 1950s, the hierarchical model of providers is basically out the window these days, and there does seem to be some residue of it in these comments. I understand that you are students, and you feel you are being advocates for the profession you are taking on, but bashing members of other healthcare professions is not constructive.

It seems rather unseemly to me for future clinicians to be behaving this way.

You don't know what you're talking about. The hierarchy exists. And it exists for a reason - for the safety of patients. PTs, PAs, NPs, etc., do not have the same understanding and knowledge of medicine as physicians, which is why they cannot fill the same role as physicians. If you don't think a hierarchy exists, then you are either in denial or you haven't worked with physician-led teams or haven't be involved in physician-led care of a patient... which I find odd.

What is that term that defines the disobedience of a NP/PA to execute the direct order of the attending physician with regard to patient care..... oh yeah, "insubordination"... Yeah, the hierarchy exists.

This isn't about ego. This is about patient safety.

 

[Sleepingdoc]

Bill Text - AB-890 Nurse practitioners: scope of practice: practice without standardized procedures.

"The bill would require the board, by regulation, to define minimum standards for a nurse practitioner to transition to practice without the routine presence of a physician and surgeon. The bill would authorize a nurse practitioner who meets certain education, experience, and certification requirements to perform, in certain settings or organizations, specified functions without standardized procedures, including ordering, performing, and interpreting diagnostic procedures, certifying disability, and prescribing, administering, dispensing, and furnishing controlled substances." etc etc

Who knows whether it'll pass but probably a matter of when, not if.

These people need to understand that these are nurses... not physicians..

 

[CoastalOT]

"It is a hierarchy" "do you actually work in a clinical setting"
"As for the rest of your email whatever"

You are a student with probably zero clinical years experience speaking to an occupational therapist who has been working in a clinical setting for years. I am dismayed at the assumptions being made, and the arrogant dismissal of points I made.

There are legitimate concerns you bring up about practice; if you think you're in a hierarchy, you're wrong. We each have a domain of practice, a physician is lead/directing care in certain domains of patient care as relevant. Some patient care decisions must be made collaboratively with the team. This was not always the case; a hierarchical mode of practice was when we were deferential to physicians for every domain for decisions to make, all the time. Like in the 1950s. With comments and attitudes like this, I suppose I can understand why you would perceive nurses as disliking you; if you walk around speaking in this patronizing manner I can't imagine many other healthcare providers would think highly of you.

I hope our medical schools are doing a good job of making sure this isn't the maturity of future practitioners emerging into multidisciplinary healthcare settings we are working in. Would you be worried if the deans of your medical schools saw these comments, or your future coworkers saw these comments with your names attached? Some of these comments are juvenile and reflect poorly upon your professional character.

 

[CoastalOT]

What is that term that defines the disobedience of a NP/PA to execute the direct order of the attending physician with regard to patient care..... oh yeah, "insubordination"... Yeah, the hierarchy exists.

This isn't about ego. This is about patient safety.

NPs and PAs are filling a necessary role in our healthcare system; we need more GPs. Many states have permitted NPs/PAs greater levels of autonomy in providing care, and I would be interested to see if the data supports your assertions regarding patient safety. With the ever rising cost of healthcare I suspect that NPs and PAs will be used in greater roles and will gain greater autonomy in providing care.

Of COURSE insubordination is the penalty for refusing to carry out a plan of care; we are now witnessing PA and NPs having autonomy and directives to widen scope of practice. People refusing to carry out their orders in the plan of care will also be insubordinate.

I have been fortunate in my years of service as an OT, we are usually referred to as "the happy people" in the hospital. I have most always enjoyed working with my colleagues. We do not have this "animosity" that doctors and nurses exhibit, in some forums/quarters and I find it unsavory. People are usually happy to see OTs as we work towards rehabilitation, it gives me great satisfaction to work with others to make this happen.

 

[deleted480308]

"It is a hierarchy" "do you actually work in a clinical setting"
"As for the rest of your email whatever"

You are a student with probably zero clinical years experience speaking to an occupational therapist who has been working in a clinical setting for years. I am dismayed at the assumptions being made, and the arrogant dismissal of points I made.

There are legitimate concerns you bring up about practice; if you think you're in a hierarchy, you're wrong. We each have a domain of practice, a physician is lead/directing care in certain domains of patient care as relevant. Some patient care decisions must be made collaboratively with the team. This was not always the case; a hierarchical mode of practice was when we were deferential to physicians for every domain for decisions to make, all the time. Like in the 1950s. With comments and attitudes like this, I suppose I can understand why you would perceive nurses as disliking you; if you walk around speaking in this patronizing manner I can't imagine many other healthcare providers would think highly of you.

I hope our medical schools are doing a good job of making sure this isn't the maturity of future practitioners emerging into multidisciplinary healthcare settings we are working in. Would you be worried if the deans of your medical schools saw these comments, or your future coworkers saw these comments with your names attached? Some of these comments are juvenile and reflect poorly upon your professional character.

what patient care decisions need to be made collaboratively? specifically.

 

[CoastalOT]

what patient care decisions need to be made collaboratively? specifically.

For instance a physiatrist and a CHT occupational therapist (hand therapist) will collaborate and determine the best path forward for a plan of care with regards to rehabilitation post surgery. In the 1950s the MD would simply say: create this splint and do these things.

 

[deleted480308]

For instance a physiatrist and a CHT occupational therapist (hand therapist) will collaborate and determine the best path forward for a plan of care with regards to rehabilitation post surgery. In the 1950s the MD would simply say: create this splint and do these things.

I think you are misrepresenting the situation there. The PT still does what the doctor wants, they just have a conversation first as a matter of courtesy or opinion gathering. But it's not a group vote. The PT can refuse to partake in something they feel is out of line but nothing happens without the doctor's approval. There is a still a hierarchy, the liability has to lie on someone.

 

[Pepe18]

For instance a physiatrist and a CHT occupational therapist (hand therapist) will collaborate and determine the best path forward for a plan of care with regards to rehabilitation post surgery. In the 1950s the MD would simply say: create this splint and do these things.

Did you work in the 1950s?

An example of non-hierarchical collaboration is a hospitalist consulting a cardiologist. The cardiologist gives their expert opinion and the hospitalist decides which parts of the recommendations they implement after a discussion.

On the PA team at my hospital, the PAs present the patient to the attending and the attending makes the plan, which the PAs then help carry out. There is some collaboration there, but also a hierarchy. In the OR, the patients safety is ultimately on the surgeon and the surgeon makes the decisions even if the resident or scrub tech has other ideas. So on. In your example, if the physician disagrees with the OT, which plan gets implemented?

Collaboration does and should occur in a hierarchy because we are a team. We train extensively to earn the right to serve patients as the experts on the team, which is why the hierarchy should exist.

CEOs/managers collaborate with other employees, but, in the end, they are the ones leading the team. A company would not allow an intern to make major financial decisions for a company, but the company leadership would be willing to hear ideas

 

[CoastalOT]

Did you work in the 1950s?

An example of non-hierarchical collaboration is a hospitalist consulting a cardiologist. The cardiologist gives their expert opinion and the hospitalist decides which parts of the recommendations they implement after a discussion.

On the PA team at my hospital, the PAs present the patient to the attending and the attending makes the plan, which the PAs then help carry out. There is some collaboration there, but also a hierarchy. In the OR, the patients safety is ultimately on the surgeon and the surgeon makes the decisions even if the resident or scrub tech has other ideas. So on. In your example, if the physician disagrees with the OT, which plan gets implemented?

Collaboration does and should occur in a hierarchy because we are a team. We train extensively to earn the right to serve patients as the experts on the team, which is why the hierarchy should exist.

CEOs/managers collaborate with other employees, but, in the end, they are the ones leading the team. A company would not allow an intern to make major financial decisions for a company, but the company leadership would be willing to hear ideas

So on. In your example, if the physician disagrees with the OT, which plan gets implemented?

The patient is under the care of the physician. The OT can decide to complain if there is a legitimate reason to do so, if they think that standard of care is not being implemented. If the patient is under the care of the NP, the NPs. If you do view healthcare primarily as a hierarchy, and you are concerned with hierarchical order as you seem to be, you will be in for a rude awakening: the hierarchy you view is expanding. NPs and PAs are filling in a gap practice; filling roles that only physicians did previously. Data will determine if that is a good thing for patient care and costs in healthcare. In hospital board rooms you will likely start to see new policies emerging, and we are. The cumulative effect of big changes happen slowly, and the effects of other providers fulfilling roles once previously reserved only for physicians have yet to reverberate throughout the way our professions conduct themselves and interact.

 

[CoastalOT]

I think you are misrepresenting the situation there. The PT still does what the doctor wants, they just have a conversation first as a matter of courtesy or opinion gathering. But it's not a group vote. The PT can refuse to partake in something they feel is out of line but nothing happens without the doctor's approval. There is a still a hierarchy, the liability has to lie on someone.

Certainly. The organizational culture was once doctor decides, OT implements, it is now clear that this is not what either of us is describing. I was asked if I have practiced in the 1950s, no I did not; however my uncle is a practicing physician who has been practicing since 1958. When he began his career he certainly "directed" all care; we have a much more collaborative role now to play. As an OT I can honestly say I have never had a disagreement with a physician at work. Our paths don't cross as often as nurses and doctor's paths do, it is for this reason that the tension which exists between your professions does exist. I have a great deal of respect for different healthcare providers, especially with regards to their roles in patient care.

This is a forum of students, perhaps many of you are under stress, and you have anxiety about the direction your field is taking, however it may be beneficial for you to reflect upon your interactions with nurses, and how you speak about your legitimate concerns about NPs etc.

 

[Pepe18]

So on. In your example, if the physician disagrees with the OT, which plan gets implemented?

The patient is under the care of the physician. The OT can decide to complain if there is a legitimate reason to do so, if they think that standard of care is not being implemented. If the patient is under the care of the NP, the NPs. If you do view healthcare primarily as a hierarchy, and you are concerned with hierarchical order as you seem to be, you will be in for a rude awakening: the hierarchy you view is expanding. NPs and PAs are filling in a gap practice; filling roles that only physicians did previously. Data will determine if that is a good thing for patient care and costs in healthcare. In hospital board rooms you will likely start to see new policies emerging, and we are. The cumulative effect of big changes happen slowly, and the effects of other providers fulfilling roles once previously reserved only for physicians have yet to reverberate throughout the way our professions conduct themselves and interact.

The OT complaining does not mean there isn’t a hierarchy there. An OT would complain only if the physician is being grossly negligent, not simply because a physician disagrees with them

You keep talking about rude awakenings. This is a forum with people with a wide range of clinical experience. Do you have any inpatient medical/non-OT experience where you can accurately judge someone’s medical management? The other day there was a NP arguing that a patient should be on antifungals because when her dad was lethargic in the hospital he had a fungal infection. The patient already had a blood cx positive for bacteria that was being treated. There is no critical thinking there

For the most part, NPs avoid situations where they are on an inpatient team without a physician. They know they aren’t trained for it. I predict that NPs who work with physicians will have data showing that NPs can help costs/have good outcomes because they are relying on the physicians to consult when things get murky. Patients being treated by unsupervised NPs will continue to be inappropriately referred for physician consults and inappropriately utilize images and treatment.

NPs are fantastic for helping on non-complex cases in clinic. They are invaluable for helping answer floor consults and presenting the information to an attending for the final plan. They are not fantastic at running teams unless they can heavily rely on the over utilization of outside physician consults. They do not have the training. I’m in a surgical field where NPs are used in the appropriate way- seeing post-op and non-complex surgical patients in clinic

All changes concerning NPs is not being driven by accurate data. It is not be driven by patient safety. It is being driven by what can save administration extra money. It’s not even saving patients’ money! It’s sad that it isn’t even about what’s best for the patient

 

[deleted480308]

Certainly. The organizational culture was once doctor decides, OT implements, it is now clear that this is not what either of us is describing. I was asked if I have practiced in the 1950s, no I did not; however my uncle is a practicing physician who has been practicing since 1958. When he began his career he certainly "directed" all care; we have a much more collaborative role now to play. As an OT I can honestly say I have never had a disagreement with a physician at work. Our paths don't cross as often as nurses and doctor's paths do, it is for this reason that the tension which exists between your professions does exist. I have a great deal of respect for different healthcare providers, especially with regards to their roles in patient care.

This is a forum of students, perhaps many of you are under stress, and you have anxiety about the direction your field is taking, however it may be beneficial for you to reflect upon your interactions with nurses, and how you speak about your legitimate concerns about NPs etc.

You clearly have a very different working definition of the word collaboration, this is no longer productive, carry on

 

[CoastalOT]

The OT complaining does not mean there isn’t a hierarchy there. An OT would complain only if the physician is being grossly negligent, not simply because a physician disagrees with you.

You keep talking about rude awakenings. This is a forum where people with a wide range of clinical experience. Do you have any inpatient medical/non-OT experience where you can accurately judge someone’s medical management? The other day there was a NP arguing that a patient should be on antifungals because when her dad was lethargic in the hospital he had a fungal infection. The patient already had a blood cx positive for bacteria that was being treated. There is no critical thinking there

For the most part, NPs avoid situations where they are on an inpatient team without a physician. They know they aren’t trained for it. I predict that NPs who work with physicians will have data showing that NPs can help costs/have good outcomes because they are relying on the physicians to consult when things get murky. Patients being treated by unsupervised NPs will continue to be inappropriately referred for physician consults and inappropriately utilize images and treatment.

NPs are fantastic for helping on non-complex cases in clinic. They are invaluable for helping answer floor consults and presenting the information to an attending for the final plan. They are not fantastic at running teams unless they can heavily rely on the over utilization of outside physician consults. They do not have the training. I’m in a surgical field where NPs are used in the appropriate way- seeing post-op and non-complex surgical patients in clinic

All changes concerning NPs is not being driven by accurate data. It is not be driven by patient safety. It is being driven by what can save administration extra money. It’s not even saving patients’ money! It’s sad that it isn’t even about patient safety

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

PURPOSE Various models of care delivery have been investigated to meet the increasing demands in primary care. One proposed model is comanagement of patients by more than 1 primary care clinician. Comanagement has been investigated in acute care with surgical teams and in outpatient settings...

www.annfammed.org

This is what NPs mean when they talk about moving from hierarchy to co-management:

"Terms such as teamwork and collaboration are often used interchangeably with comanagement. Comanagement involves a horizontal organizational structure. Clinicians may comanage across teams in a manner similar to a primary care physician and a cardiologist comanaging the same patient. These 2 physicians work within their own teams within their practices, but overlap horizontally to comanage the same patient. Within the same team, an independent nurse practitioner may comanage the same patient with a physician, in the same practice, based on the urgency or complexity of a patient’s needs."

I will refrain from any comment about the argument that I had no part in between you and an NP. Do you have any data to support the assertion that patient care is being compromised by independent practice by NP and PAs? If so, post it. If your assertions are correct let's see the data to support this, and if it isn't out there it should be compiled. There seem to be a lot of very concerned physicians about the expanding independence and role of NPs, so where's the data?

I agree with you re the utilization of NPs for the reasons you cite, it seems quite logical, and prescient to developments occurring today in healthcare. Re my points about data and expanding role of NPs, I think this debate can be had with respect, and decorum. I don't see much of that these days.

 

[CoastalOT]

You clearly have a very different working definition of the word collaboration, this is no longer productive, carry on

Very well. Have a great day. Carry on.

 

[CoastalOT]

Stop calling physicians ‘providers’. I didn’t go to provider school and there 100% is a hierarchy. Until you can go through the rigorous schooling and training physicians did, passed the insane exams and boards physicians did, make the independent decisions physicians make and then take all the legal liability there 100% will be a hierarchy. Your viewpoint is myopic and naive and not representative of the real world.

If your assertion were correct and this is a "100% hierarchy" with doctors on top if NP and PA roles are expanding as they are. Nurse practitioners and PAs are independently managing patient care in some states, and in the VA NPs are doing so. It appears that NPs and PAs see view their profession more as co-managers of patient care, and are permitted more and more independence as practitioners. This is the real world, welcome to it.

You are a healthcare provider, and a physician. Please do not let your ego get in the way of a rational discussion, your response seems motivated by emotion and not logic. I suspect that your bristly response is why some nurses who incorrectly form judgments on an entire profession could have the impression that physicians are arrogant? This kind of discourse is counterproductive. I am curious though, and I will be discussing these issues with my NP friends next time I see them.

 

[Pepe18]

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

PURPOSE Various models of care delivery have been investigated to meet the increasing demands in primary care. One proposed model is comanagement of patients by more than 1 primary care clinician. Comanagement has been investigated in acute care with surgical teams and in outpatient settings...

www.annfammed.org

This is what nurses mean when they talk about moving from hierarchy to co-management:

"Terms such as teamwork and collaboration are often used interchangeably with comanagement. Comanagement involves a horizontal organizational structure. Clinicians may comanage across teams in a manner similar to a primary care physician and a cardiologist comanaging the same patient. These 2 physicians work within their own teams within their practices, but overlap horizontally to comanage the same patient. Within the same team, an independent nurse practitioner may comanage the same patient with a physician, in the same practice, based on the urgency or complexity of a patient’s needs."

I will refrain from any comment about the argument that I had no part in between you and an NP. Do you have any data to support the assertion that patient care is being compromised by independent practice by NP and PAs? If so, post it. I am not arguing for or against, I support learning new things.

I must say I agree with you re the utilization of NPs for the reasons you cite, it seems quite logical, and prescient to developments occurring today in healthcare. My initial post was about tone, not content necessarily for the record.

I can share articles when I have access to my computer later today.

I agree physicians do get worked up and use the wrong tone, which ends up making discussions non-productive. However, most of us have seen patients hurt by mid level treatment, so we are fired up about the issue. This is also a forum for MD and MDs students. You are being a voyeur by coming in and reading our venting and then trying to police our passion to protect patients.

The horizontal collaboration does not work because the physician does not stand to gain any expertise from the NP. As a med student, I helped NPs interpret basic labs, the diabetes focused NPs I’ve worked with did not know how to dose insulin, we had to explain antibiotic stewardship and inappropriate use of broad spectrum antibiotics, etc. The knowledge is one way from the physician to the NP. It’s like working in a group project, doing all the hard work, and then someone else gets credit.

In my example with the hospitalist and the cardiologist, each physician brings their extensive training and expertise to the picture and they discuss how the nuances of a case should change the plan. The other issue with independent co-management is that NPs would then have the option to work independently without a physician comanager. Working as a team with a physician leader allows NPs to come up with plans, while also having quality insurance by having the input of physician expertise

 

[CoastalOT]

I can share articles when I have access to my computer later today.

I agree physicians do get worked up and use the wrong tone, which ends up making discussions non-productive. However, most of us have seen patients hurt by mid level treatment, so we are fired up about the issue. This is also a forum for MD and MDs students. You are being a voyeur by coming in and reading our venting and then trying to police our passion to protect patients.

The horizontal collaboration does not work because the physician does not stand to gain any expertise from the NP. As a med student, I helped NPs interpret basic labs, the diabetes focused NPs I’ve worked with did not know how to dose insulin, we had to explain antibiotic stewardship and inappropriate use of broad spectrum antibiotics, etc. The knowledge is one way from the physician to the NP. It’s like working in a group project, doing all the hard work, and then someone else gets credit.

In my example with the hospitalist and the cardiologist, each physician brings their extensive training and expertise to the picture and they discuss how the nuances of a case should change the plan. The other issue with independent co-management is that NPs have the option to work independently without a physician comanager. Working as a team with a physician leader allows NPs to come up with plans, while also having quality insurance by having the input of physician expertise

You're correct, I am a voyeur, this is your "pet area" in which you get to vent like the teachers lounge when we were younger where the teachers get to let off steam. I look forward to reading what you send me.

This is an opportunity to explore and dialogue with another person who works with patients (can I use that term or will someone get upset) about this issue. I will be interested to read if patient safety negatively affected by NP's expanding independent practice. You do have greater education and relevant clinical experience as a medical student; but when you are contrasted with an experienced NP in an appropriate practice (say primary care) do we see that diminish? I am aware that nurses are territorial about their course content and program structure, however, maybe they should include a "residency" of sorts in their programs to gain more clinical experience. I have a friend who just completed his NP in family medicine and only did a few hundred hours of clinical rotations; with the rationale that he has years of experience as a nurse. Perhaps this needs to be re-assessed?

Nothing online is private these days. If you carry the mantle of being a physician so highly, then you should act like it is an honor and behave accordingly. In our society today, (look at the antics in govt) we reward narcissism and egomania, it would be nice to have healthcare providers remaining above the fray. Yes, I said providers, that means all of us. When you discuss these issues with NPs and the debate gets into the public arena, the tone that each field is using in dark corners will seep into the well poisoning the water and hindering problem solving without defensiveness. It is important for all clinicians to place ego off to the side about ancillary issues unrelated to patient care: e.g., who gets to wear a white coat (the horror!). The VA debacle that recently occurred between NPs and MDs was cringey for me to read about.

 

[deleted480308]

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

PURPOSE Various models of care delivery have been investigated to meet the increasing demands in primary care. One proposed model is comanagement of patients by more than 1 primary care clinician. Comanagement has been investigated in acute care with surgical teams and in outpatient settings...

www.annfammed.org

This is what NPs mean when they talk about moving from hierarchy to co-management:

"Terms such as teamwork and collaboration are often used interchangeably with comanagement. Comanagement involves a horizontal organizational structure. Clinicians may comanage across teams in a manner similar to a primary care physician and a cardiologist comanaging the same patient. These 2 physicians work within their own teams within their practices, but overlap horizontally to comanage the same patient. Within the same team, an independent nurse practitioner may comanage the same patient with a physician, in the same practice, based on the urgency or complexity of a patient’s needs."

I will refrain from any comment about the argument that I had no part in between you and an NP. Do you have any data to support the assertion that patient care is being compromised by independent practice by NP and PAs? If so, post it. If your assertions are correct let's see the data to support this, and if it isn't out there it should be compiled. There seem to be a lot of very concerned physicians about the expanding independence and role of NPs, so where's the data?

I agree with you re the utilization of NPs for the reasons you cite, it seems quite logical, and prescient to developments occurring today in healthcare. Re my points about data and expanding role of NPs, I think this debate can be had with respect, and decorum. I don't see much of that these days.

I guess I'm not ready to bow out yet if your going to drop stuff like this.

That's a dishonest representation. What that actually means is "we want to get paid independently and have the freedom to do what we want, but we're still cool with being a "co-manager" (partially as a negotiation tactic to get independence) so that when something is over our heads we still get to boot the care to a better trained doctor who now shares liability but doesn't get to order me around.

I get that you are debating going NP or doctor given your dissatisfaction with OT. But I'm out here actually reading charts and getting presentations by nps and pas every week. The training isn't good enough for them to be independent. The quality difference is noticeable. They aren't ready. If you really want to be a decision maker, go to med school.

 

[Espressso]

You're correct, I am a voyeur, this is your "pet area" in which you get to vent like the teachers lounge when we were younger where the teachers get to let off steam.


This is useful to educate another healthcare provider about this issue. I will be interested to read about the data, is patient safety negatively affected by NP's expanding independent practice? You do have greater education and relevant clinical experience as a medical student; but when you are contrasted with an experienced NP in an appropriate practice (say primary care) do we see that diminish? I am aware that nurses are territorial about their course content and program structure, however, maybe they should include a "residency" of sorts in their programs to gain more clinical experience. I have a friend who just completed his NP in family medicine and only did a few hundred hours of clinical rotations; with the rationale that he has years of experience as a nurse. Perhaps this needs to be re-assessed?

Nothing online is private these days. If you carry the mantle of being a physician so highly, then you should act like it is an honor and behave accordingly. In our society today, (look at the antics in govt) we reward narcissism and egomania, it would be nice to have healthcare providers remaining above the fray. Yes, I said providers, that means all of us. When you discuss these issues with NPs and the debate gets into the public arena, the tone that each field is using in dark corners will seep into the well poisoning the water and hindering problem solving without defensiveness. It is important for all clinicians to place ego off to the side about ancillary issues unrelated to patient care: e.g., who gets to wear a white coat (the horror!). The VA debacle that recently occurred between NPs and MDs was cringey for me to read about.

Yes. This needs to be re-assessed. That's a giant crux of this entire debate. The entire NP scope of practice needs to be addressed. Which is what these students and physicians are trying to explain. And to be quite honest, these physicians commenting on this thread have made it clear that they work with NPs who help and do great things with their teams. But the issue is of NP independence. I'm confused how you don't seem to understand the motive of administrative cost savings as a rationale to push more NPs into independent practice. Obviously it's a cheaper solution. The physicians are saying, hey wait a minute. They aren't adequately trained to be independent. This is really not a confusing issue. You seem to be making it one.

If you look at the history of NP as a profession. It was designed to be a mid-level provider for nurses who have had 20-30 years of nursing experience, to be able to help the lead physician with the less complex cases. What we're seeing now is not that. Online NP schools pumping out NPs with less than 5 years of nursing experience, then going on to become independent practitioners. This is the problem because it puts patients at risk. How you can argue otherwise is beyond me.

This isn't even taking into account the nursing union that is funding many of these state legislators and pushing for these independent NP laws. Which is a whole separate topic entirely.

 

[CoastalOT]

I guess I'm not ready to bow out yet if your going to drop stuff like this.

That's a dishonest representation. What that actually means is "we want to get paid independently and have the freedom to do what we want, but we're still cool with being a "co-manager" (partially as a negotiation tactic to get independence) so that when something is over our heads we still get to boot the care to a better trained doctor who now shares liability but doesn't get to order me around.

I get that you are debating going NP or doctor given your dissatisfaction with OT. But I'm out here actually reading charts and getting presentations by nps and pas every week. The training isn't good enough for them to be independent. The quality difference is noticeable. They aren't ready. If you really want to be a decision maker, go to med school.

Please refrain from ad hominem attacks and conjecture about my life. I will report you for conduct that is unbecoming. I hope, truly, that your behavior here is not representative of your professional tone.

I get that you are debating going NP or doctor given your dissatisfaction with OT. - AD HOMINEM ATTACK
But I'm out here actually reading charts and getting presentations by nps and pas every week. -- ANECDOTAL
The training isn't good enough for them to be independent. - ANY DATA?
The quality difference is noticeable. They aren't ready. If you really want to be a decision maker, go to med school. - DATA?