The Doctor Nurse will see you now.

[deleted1183938]

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The Doctor Or Nurse Practitioner Will See You. Does It Matter?

Americans are increasingly likely to get healthcare from nurse practitioners. Data shows NPs can provide safe and effective care with physician partnership and oversight.

www.forbes.com

America the great.

 

[Gern Blansten]

“What the eye doesn't see and the mind doesn't know, doesn't exist.”
- D.H. Lawrence, Lady Chatterley's Lover

or

"If I didn't believe it, I wouldn't have seen it"
-Ken Kesey

Or, put more simply, you must have the knowledge to understand what you are seeing to have any hope of understanding it. They don't know what they don't know.

 

[TheLoneWolf]

"You don't know what you don't know."

Heard it from practically every attending at my program who graduated before the 90s

 

[deleted1112838]

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[skougess]

Midlevels don’t want to go to the rural places either…

 

[TheLoneWolf]

Midlevels don’t want to go to the rural places either…

Bingo

 

[deleted1112838]

.

 

[TheLoneWolf]

If you licensed them to only work in rural America, some discussion could be had. Rather, they are in every major medical center and compromise at least half of the anesthesia staff in those facilities.

 

[TheLoneWolf]

Here's the deal everybody wants to complain about these mid-level providers but no doctors want to actually work in rural America where I come from and where people need care. If you want to complain about the mid-level providers being around then you need to get out of New York City and all these bozo cesspool lib places and go actually treat patients where they need help and stop driving your Audis and living with your second wives and high rises.

There ain't enough doctors to treat everybody I'm obviously not saying the mid levels are doctors, doctors are better than mid levels but we got a lot of people in America that need health care so what the hell do you want to do?

Why the hell you think we got AAs and CRNAs?

They do medical care with our oversight that's literally what's going on at these other places.

England, Canada, Australia and New Zealand don't have enough anesthesia staff to cover their needs yet they don't allow nurse anesthetists. It's called having medical standards.

 

[deleted1112838]

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[deleted1112838]

N

 

[TheLoneWolf]

I can truly promise you I don't give an absolute flying f*** what countries other than the United States do.

We are number one and I am not interested in anybody else.

I literally just showed you several other western countries with high standards of living and they can get by just fine without compromising.

Also, let's try to keep things civil here.

 

[Fpg1245]

I literally just showed you several other western countries with high standards of living and they can get by just fine without compromising.

Also, let's try to keep things civil here.

It’s in the username. PE came knocking.

 

[KaiBuzz]

Here's the deal everybody wants to complain about these mid-level providers but no doctors want to actually work in rural America where I come from and where people need care. If you want to complain about the mid-level providers being around then you need to get out of New York City and all these cesspool lib places and go actually treat patients where they need help and stop driving your Audis and living with your second wives and high rises.

There ain't enough doctors to treat everybody I'm obviously not saying the mid levels are doctors, doctors are better than mid levels but we got a lot of people in America that need health care so what the hell do you want to do?

Why the hell you think we got AAs and CRNAs?

They do medical care with our oversight that's literally what's going on at these other places.

Second wives? Some of us are actually women here working in red states….

 

[Maz777]

Don't feed the troll.

 

[ChiDO]

Simple answer is compensatation. Decrease administrative costs and transfer that money to pay for rural Drs and night shifts. Don't need to lower standards to mid levels,who are basically costing almost the same now.

 

[deleted87051]

Here's the deal everybody wants to complain about these mid-level providers but no doctors want to actually work in rural America where I come from and where people need care. If you want to complain about the mid-level providers being around then you need to get out of New York City and all these cesspool lib places and go actually treat patients where they need help and stop driving your Audis and living with your second wives and high rises.

There ain't enough doctors to treat everybody I'm obviously not saying the mid levels are doctors, doctors are better than mid levels but we got a lot of people in America that need health care so what the hell do you want to do?

Why the hell you think we got AAs and CRNAs?

They do medical care with our oversight that's literally what's going on at these other places.

Coastal cities also need doctors and are short staffed too.

 

[PAC2DO]

As a former mid level provider, I do agree with the statement of “you don’t know what you don’t know”. There is a major knowledge gap between mid level providers vs physician. That doesn’t mean that there is a major gap in clinical outcome. I do believe we need mid level providers in this country and they mostly do fine. However, I have a problem when the mid level providers act in lieu of physicians just bc their degree says “doctorate” or doesn’t consult physicians appropriately. But then… going back to my previous statement - they don’t know what they don’t know.

I believe mid levels are utilized best in areas such as surgical field where you have a direct supervision/EM fast track with a supervising attending to eyeball every pt/outpatient med refill/follow ups/triage type of work.

 

[chewswithteeth]

Midlevels don’t want to go to the rural places either…

Very funny to see in the Reddit CRNA thread about opt out in MA, all of the CRNAs were bemoaning that it would likely only mean independent practice in “rural areas” where they don’t want to go.

 

[Hoya11]

England, Canada, Australia and New Zealand don't have enough anesthesia staff to cover their needs yet they don't allow nurse anesthetists. It's called having medical standards.

Maybe it has to do with the fact that all of those countries have universal health care, whereas we have private industry driving surgeons to go go go now now now. Try this new implantable device its great!

I'm all for MD only care. Absolutely. But we have to take a look in the mirror as a country and make some changes to the way we utilize healthacre before we could make that happen. We have to staff all of these silly little cases in all of these different locations with minimal wait time. So we have to sacrifice quality. And I agree that right now our quality is at an all time low. And its not just CRNAs, PAs can be equally scary.

 

[AKMD_1984]

Then find the doctors to staff the hospital. Find them. We are not the same as mid levels but we don't have enough physicians to do all the work. Hell we can't find enough physicians to staff the hospitals anyways because nobody wants to work nights weekends are call anymore cuz everybody is a total lightweight.

So the problem is not the mid levels are the problem the problem is that there is just so many people out there that need care and that's a fact of life. Hounding mid levels is good and well but if you get rid of them I hope you are ready to work more shifts and take more patients.

You’re talking a lot of nonsense

 

[DrOwnage]

Then find the doctors to staff the hospital. Find them. We are not the same as mid levels but we don't have enough physicians to do all the work. Hell we can't find enough physicians to staff the hospitals anyways because nobody wants to work nights weekends are call anymore cuz everybody is a total lightweight.

So the problem is not the mid levels are the problem the problem is that there is just so many people out there that need care and that's a fact of life. Hounding mid levels is good and well but if you get rid of them I hope you are ready to work more shifts and take more patients.

Large percentage of midlevels don’t even take call, work 3-4 days a week and take 9-13 weeks of vacation. I’m missing the point here? You’re hounding on physicians because they won’t take all the ****ty parts of the job getting paid only slightly more? We created a problem filling the void and your solution is the **** on the OGs. Like what…

 

[deleted1183938]

England, Canada, Australia and New Zealand don't have enough anesthesia staff to cover their needs yet they don't allow nurse anesthetists. It's called having medical standards.

Exactly.

 

[deleted1183938]

Maybe it has to do with the fact that all of those countries have universal health care, whereas we have private industry driving surgeons to go go go now now now. Try this new implantable device its great!

I'm all for MD only care. Absolutely. But we have to take a look in the mirror as a country and make some changes to the way we utilize healthacre before we could make that happen. We have to staff all of these silly little cases in all of these different locations with minimal wait time. So we have to sacrifice quality. And I agree that right now our quality is at an all time low. And its not just CRNAs, PAs can be equally scary.

Forget CRNAs and PAs. They at least have standards and minimum requirements to get in.
I don’t know if you guys know that you can actually become an NP these days without any bedside experience and even never being an RN before.
That is scary as hell and I spend every week telling patiens to go get care by an actual physician because I see so much mismanagement. In rural America.

 

[deleted1183938]

I can truly promise you I don't give an absolute flying f*** what countries other than the United States do.

We are number one and I am not interested in anybody else.

Number one in what exactly?

 

[deleted1183938]

Here's the deal everybody wants to complain about these mid-level providers but no doctors want to actually work in rural America where I come from and where people need care. If you want to complain about the mid-level providers being around then you need to get out of New York City and all these cesspool lib places and go actually treat patients where they need help and stop driving your Audis and living with your second wives and high rises.

There ain't enough doctors to treat everybody I'm obviously not saying the mid levels are doctors, doctors are better than mid levels but we got a lot of people in America that need health care so what the hell do you want to do?

Why the hell you think we got AAs and CRNAs?

They do medical care with our oversight that's literally what's going on at these other places.

I do locums at these places. And let me tell you something, these patients are being highly mismanagement by these NPs
So tell me, do you think these rural farmers, Salt of the earth, who keep America fed deserve to be given poorer care simply because they live and love rural America?
And BTW, there are doctors in these rural places and when they get treated well by admin, they stay for many years and even decades. Doctors from the cities stay for decades because taking care of rural patients in general is a whole different ballgame and the money is usually pretty good.
Of course let’s not forget that there are doctors from rural America who want to go back home.
The reason people like you think we “need” midlevels in rural America is because healthcare in this country is treated like a money machine. And given your username, it all fits why you are in this machine.
Arguments like these are idiotic considering how poorly we fare in our care and outcomes compared to other developed countries.

 

[deleted1112838]

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[gunnershow]

Those people are my people cause I'm from there you can't tell me nothing about that ****. Doing locums there don't mean you know nothing.

Can this dolt be run off this board already

 

[deleted1183938]

Those people are my people cause I'm from there you can't tell me nothing about that ****. Doing locums there don't mean you know nothing.

Well then clearly you don’t give a **** about “those” people.
And don’t tell me what I know or don’t know. All you seem to care about and know about is money.

Gosh darn it people like me!!! They really like me!!! Hahahha.

 

[deleted1183938]

Can this dolt be run off this board already

Ok now I need to look up the definition of dolt.

Edit: Thanks @gunnershow for making me laugh and teaching me a new word!!

 

[AKMD_1984]

Make money and medicine2wall street appear to be two sides of same coin

I can’t decide who’s more cringeworthy

 

[deleted1183938]

Make money and medicine2wall street appear to be two sides of same coin

I can’t decide who’s more cringeworthy

Except you won’t catch me on these boards trying to convince a bunch of strangers that

“Gosh darn it, People like me!! They really like me!” Cuz don’t really care what internet people think of me. lol. This is not my real life and I don’t care if I make you cringeworthy.

 

[AKMD_1984]

Except you won’t catch me on these boards trying to convince a bunch of strangers that

“Gosh darn it, People like me!! They really like me!” Cuz don’t really care what internet people think of me. lol. This is not my real life and I don’t care if I make you cringeworthy.

Yet here you are …

 

[deleted1183938]

Yet here you are …

Are you slow? Can you read? Comprehend English?
Because clearly you think I give a flying F that you dislike me. Some internet Rando!!! Hahaha

 

[AKMD_1984]

Are you slow? Can you read? Comprehend English?
Because clearly you think I give a flying F that you dislike me. Some internet Rando!!! Hahaha

No need to dignify that with a comment.

Good luck.

 

[deleted1183938]

No need to dignify that with a comment.

Good luck.

You care to be relevant to me so badly. You aren’t.
Good luck with what exactly? Popularity politics? lol

 

[cchoukal]

I'm wondering if they're EITHER the same person or if they've maybe made out once or twice.

 

[Spikebd]

Simple answer is compensatation. Decrease administrative costs and transfer that money to pay for rural Drs and night shifts. Don't need to lower standards to mid levels,who are basically costing almost the same now.

Rural health is getting hit pretty hard. The days of the rural premium pay for physicians seems to be rapidly disappearing. The rural places are gonna be skeleton shops that operate at dangerously low staffing, just enough to provide emergency care. I am sensing a shift of where they’re pushing lots of us doctors to major metro areas and away from these rural spots. Source: myself where my small rural hospital got bought out by a larger entity who then cut most of our staff pay and put us on an RVU model.

 

[jwk]

Here's the deal everybody wants to complain about these mid-level providers but no doctors want to actually work in rural America where I come from and where people need care. If you want to complain about the mid-level providers being around then you need to get out of New York City and all these cesspool lib places and go actually treat patients where they need help and stop driving your Audis and living with your second wives and high rises.

There ain't enough doctors to treat everybody I'm obviously not saying the mid levels are doctors, doctors are better than mid levels but we got a lot of people in America that need health care so what the hell do you want to do?

Why the hell you think we got AAs and CRNAs?

They do medical care with our oversight that's literally what's going on at these other places.

You haven’t mentioned it so I’ll assume you’re not aware of the financial incentives for rural hospitals to use CRNAs and NOT physicians. The rural pass-through issue keeps many docs from going to rural areas.

 

[mmag]

You haven’t mentioned it so I’ll assume you’re not aware of the financial incentives for rural hospitals to use CRNAs and NOT physicians. The rural pass-through issue keeps many docs from going to rural areas.

Yep, I can't get a job in my rural hometown or even within an hour because of rural pass through at the local critical access and the crna cartel at the "regional" hospital - all crna group with an exclusive contract. Med school classmate managed to get hired in rural Kansas only because the hospital wanted very badly her surgeon husband. Had to piss off the crnas but hey no work for them either without a surgeon.

 

[deleted1183938]

Yep, I can't get a job in my rural hometown or even within an hour because of rural pass through at the local critical access and the crna cartel at the "regional" hospital - all crna group with an exclusive contract. Med school classmate managed to get hired in rural Kansas only because the hospital wanted very badly her surgeon husband. Had to piss off the crnas but hey no work for them either without a surgeon.

How big is this “regional” hospital?
And how did she work with the CRNAs? She does her own cases and they do theirs? Had they ever had docs?

 

[deleted1183938]

You haven’t mentioned it so I’ll assume you’re not aware of the financial incentives for rural hospitals to use CRNAs and NOT physicians. The rural pass-through issue keeps many docs from going to rural areas.

What about for NPs? Not aware of anything like this for them.

 

[mmag]

How big is this “regional” hospital?
And how did she work with the CRNAs? She does her own cases and they do theirs? Had they ever had docs?

200+ beds... Director of anesthesia is a CRNA.
She did her own cases in her room. Crnas did their cases in their room. Never had anesthesiologists before.

 

[deleted1183938]

200+ beds... Director of anesthesia is a CRNA.
She did her own cases in her room. Crnas did their cases in their room. Never had anesthesiologists before.

Has she dished out to you how the CRNAs are performing? Just curious.

 

[anonanes]

Yeah I mean there are a lot of them that don't want to go there either but the complain about mid level providers is driving me insane and I have absolutely had it with these doctors that complain about mid levels when there ain't enough doctors to treat everyone. It would literally take 40 + anesthesiologist to staff my residency program what the hell do you want to do get rid of all the crnas?

Yeah mid levels should not identify as doctors and I don't agree with that at all but they are a necessary component of the healthcare system. It's just a fact.

I've seen and heard of plenty of midlevels state that they don't need the doctor- and they there is nothing they can't do that doctors do. I think that is the the reason some doctors don't enjoy working with midlevels - I've had the same sentiment. Midlevels are nothing more than lifelong residents - some are great, others are not. Difference with a resident though - generally speaking, they listen and recognize their limitations. I'm not against midlevels - I recognize the shortage and the help needed in the healthcare system - but when you have midlevels being more of a impediment to the care you want to provide - I'm not interested. More often than not, it's not a collaborative team effort when you have midlevels. In the anesthesia world - when you're supervising 1:3 or 1:4 or more - why should we be attesting to being present on induction or emergence if we're not there.

My first job out of training - supervising. I reached out to group president and expressed my concerns that I had 4 rooms - in one of the rooms, CRNA had intubated and placed an a-line in without my presence. His response to me: don't worry about it. These guys have done more airways when you have. My response: Then why am I here? Quit 6months later.

I love my job - but once I'm forced to be a person who only signs consents and supervises - I'm out and done with medicine. That's not why I became an anesthesiologist.

 

[2Fast2Des]

I've seen and heard of plenty of midlevels state that they don't need the doctor- and they there is nothing they can't do that doctors do. I think that is the the reason some doctors don't enjoy working with midlevels - I've had the same sentiment. Midlevels are nothing more than lifelong residents - some are great, others are not. Difference with a resident though - generally speaking, they listen and recognize their limitations. I'm not against midlevels - I recognize the shortage and the help needed in the healthcare system - but when you have midlevels being more of a impediment to the care you want to provide - I'm not interested. More often than not, it's not a collaborative team effort when you have midlevels. In the anesthesia world - when you're supervising 1:3 or 1:4 or more - why should we be attesting to being present on induction or emergence if we're not there.

My first job out of training - supervising. I reached out to group president and expressed my concerns that I had 4 rooms - in one of the rooms, CRNA had intubated and placed an a-line in without my presence. His response to me: don't worry about it. These guys have done more airways when you have. My response: Then why am I here? Quit 6months later.

I love my job - but once I'm forced to be a person who only signs consents and supervises - I'm out and done with medicine. That's not why I became an anesthesiologist.

These spineless sellouts are everything that's wrong with this field...

 

[jwk]

What about for NPs? Not aware of anything like this for them.

There's not. It's a CMS quirk that applies to anesthesia services. What's strange is that CAAs are eligible as well - except CAAs can't work without anesthesiologists, and CAHs are too small a volume to have multiple anesthesia staff.

From the ASA...
Under the “pass-through” program, eligible hospitals may use reasonable-costs based Part A payments in lieu of the conventional Part B payments as a rural practice inducement for non-physician anesthesia providers such as anesthesiologist assistants (a type of physician assistant) and nurse anesthetists to practice in small, low volume rural hospitals. Under the Centers for Medicare and Medicaid Services (CMS) current interpretation of the current “pass-through” program, eligible small rural hospitals are not permitted to use the “pass-through” funds to hire physician anesthesiologists.

 

[WhatJobDoIPick]

Hello from the ED.

Midlevels function best when they do what they were meant to be: physician extenders.

In my previous trash job (hospital employed), the midlevels were awful. High confidence, low ability. Just at that sweet spot of the dunning kruger curve. First year grads would question seasoned attendings. They were slow as hell.

Contrast to current private group job. Wow the midlevels are great. Fast, competent, a pleasure to work with. We get half the RVUs for the cases they present to us. They are highly competent, but still present a lot of cases.

Night and day.

 

[Gern Blansten]

Hello from the ED.

Midlevels function best when they do what they were meant to be: physician extenders.

In my previous trash job (hospital employed), the midlevels were awful. High confidence, low ability. Just at that sweet spot of the dunning kruger curve. First year grads would question seasoned attendings. They were slow as hell.

Contrast to current private group job. Wow the midlevels are great. Fast, competent, a pleasure to work with. We get half the RVUs for the cases they present to us. They are highly competent, but still present a lot of cases.

Night and day.

I agree. The attitude and approach of the person that you are working with makes all the difference. Physicians are not innocent in this and a physician with a terrible attitude can turn a great CRNA/NP/PA into one with a horrible attitude. So, it really is a two way street. There are certainly ways to provide oversight without being demeaning. Some mid levels are so entitled, that this doesn't really matter. But there are a small subset of excellent mid-levels that can be tipped into the militant zone if they are treated poorly.
So, I am not disagreeing with you, just pointing out that to have an excellent work environment as a supervising physician requires some effort on our part as well, which I am sure you must do based on your description of the positive work environment at your new place.

 

[deleted1183938]

Hello from the ED.

Midlevels function best when they do what they were meant to be: physician extenders.

In my previous trash job (hospital employed), the midlevels were awful. High confidence, low ability. Just at that sweet spot of the dunning kruger curve. First year grads would question seasoned attendings. They were slow as hell.

Contrast to current private group job. Wow the midlevels are great. Fast, competent, a pleasure to work with. We get half the RVUs for the cases they present to us. They are highly competent, but still present a lot of cases.

Night and day.

This literally has been my most recent experience in the OR over the past few months. One group of horribly over confident CRNAs who literally killed some patients and refused to call for help when needed and then the following a group of CRNAs at another who believed in teamwork and were competent and a pleasure to work with.
The difference I think was the leadership. I literally didn't know the latter group existed and it has been a nice pleasure to work with them. The chiefs get rid of the ones with bad attitudes.