Vanderbuilt Starts Acute Care Nurse Practitioner Intensivist Fellowship

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Be careful who you train.

Acute Care Nurse Practitioner Intensivist Fellowship created

Vanderbilt University Medical Center has developed a pilot Acute Care Nurse Practitioner (ACNP) Intensivist Fellowship program run jointly by Vanderbilt University School of Nursing and the Department of Anesthesiology-Division of Critical Care Medicine.​
 

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Vanderbuilt Starts Acute Care Nurse Practitioner Intensivist Fellowship

Be careful who you train.

Acute Care Nurse Practitioner Intensivist Fellowship created

Vanderbilt University Medical Center has developed a pilot Acute Care Nurse Practitioner (ACNP) Intensivist Fellowship program run jointly by Vanderbilt University School of Nursing and the Department of Anesthesiology-Division of Critical Care Medicine.​
No 'u' in Vanderbilt and see also:

http://forums.studentdoctor.net/showthread.php?t=914669
 

justaregularmed

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While there is plenty of good back and forth in the thread at the end of the day this is purely a greed thing. Its all about the money. For some reason vanderbilt cant be bothered to post their tuition costs, which is sketchy. Best I can tell there are at least 3 courses for the "fellowship" and at over 1,000 dollars a credit who wouldn't want to train them? You have the government as a source of infinite money that is 100% guaranteed, its a racket how can you go wrong?

In the end the whole DNP movement is purely greed based. Why get 2 years of tuition when you can force people to pay four? Please.
 

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While there is plenty of good back and forth in the thread at the end of the day this is purely a greed thing. Its all about the money. For some reason vanderbilt cant be bothered to post their tuition costs, which is sketchy. Best I can tell there are at least 3 courses for the "fellowship" and at over 1,000 dollars a credit who wouldn't want to train them? You have the government as a source of infinite money that is 100% guaranteed, its a racket how can you go wrong?

In the end the whole DNP movement is purely greed based. Why get 2 years of tuition when you can force people to pay four? Please.
I guess I simply don't understand this whole movement. Who certifies these people, and how are they allowed to practice? Shouldn't the AMA put its foot down? Why are we having doctors go through all this training when nurses get a little degree and do the same job? Can we decide to go with one or the other? It's ridiculous
 

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I guess I simply don't understand this whole movement. Who certifies these people, and how are they allowed to practice? Shouldn't the AMA put its foot down? Why are we having doctors go through all this training when nurses get a little degree and do the same job? Can we decide to go with one or the other? It's ridiculous
The issue is that advance practice nurses are regulated by state boards of nursing rather than of medicine. Those are (unsurprisingly) run by nurses, and that's who sets their scope of practice. Physicians have very little say in it other than by legislative efforts. That's also the reason there's more overreach by NPs than PAs--PAs are regulated by the boards of medicine.
 
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The issue is that advance practice nurses are regulated by state boards of nursing rather than of medicine. Those are (unsurprisingly) run by nurses, and that's who sets their scope of practice. Physicians have very little say in it other than by legislative efforts. That's also the reason there's more overreach by NPs than PAs--PAs are regulated by the boards of medicine.
I still don't think that makes any sense. Shouldn't a neutral body regulate this? Why not have them claim that they are doctors and don't need any supervision, and have them as attendings then?
 

europeman

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I'm a future intensivist and I think this is a great idea. Lots of ICUs have NPs or PAs... This is just a formal way to get them trained for that role.

The best run. ICUs have NPs and an attending MD. The Icu with 2nd year residents and senior residents plus/minus fellow are more dangerous but obviously an inherent necessity of training.

Anyway.... Fact is there are not enough intensivists out there.... So I see nothing wrong with, for example, an in house NP running a unit with attending backup at home. It's sure better than having a second or third year resident in there with attending backup at home!

Now NPs will never, ever, independently run a unit without an MD.
 

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I'm a future intensivist and I think this is a great idea. Lots of ICUs have NPs or PAs... This is just a formal way to get them trained for that role.

The best run. ICUs have NPs and an attending MD. The Icu with 2nd year residents and senior residents plus/minus fellow are more dangerous but obviously an inherent necessity of training.

Anyway.... Fact is there are not enough intensivists out there.... So I see nothing wrong with, for example, an in house NP running a unit with attending backup at home. It's sure better than having a second or third year resident in there with attending backup at home!

Now NPs will never, ever, independently run a unit without an MD.
The bold statement is short-sited and naive. They will take as much as they are allowed, and that is more and more each year. Frankly I find your comments about preferring them over a mid-level resident disturbing. No other profession on the planet tries as hard as medicine to make themselves unnecessary, and I just do not get it.
 

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I'm a future intensivist and I think this is a great idea. Lots of ICUs have NPs or PAs... This is just a formal way to get them trained for that role.

The best run. ICUs have NPs and an attending MD. The Icu with 2nd year residents and senior residents plus/minus fellow are more dangerous but obviously an inherent necessity of training.

Anyway.... Fact is there are not enough intensivists out there.... So I see nothing wrong with, for example, an in house NP running a unit with attending backup at home. It's sure better than having a second or third year resident in there with attending backup at home!

Now NPs will never, ever, independently run a unit without an MD.
I am myself very interested in critical care and I really do not understand what's in bold. In which way is it better to have a nurse rather than an in-house resident making decisions if an unstable patient (remember we're in an ICU) become even more unstable?
 

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Now NPs will never, ever, independently run a unit without an MD.

BS. You would have said the same thing about NPs being called "intensivists" and completing a "critical care fellowship" 15 years ago too.
 

europeman

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Jeez guys!

First of all.... We have to get with reality. There is a shortage of intensivists in the near future and we live in an era of work hour regulations. So we mUST work with midlevels.

That said my comment was meant as the following: an EXPERIENCED NP is much more capable of managing and dealing with critically sick patients compared to a bright eyed second year resident in July. Now one could argue.... Maybe there are some things a good third year surgery or anesthesia or medicine resident could do that may have an up on even an experiences NP. That's true. But on average, I think you are underestimating the ability of these midlevels once they gain experience. EXPERIENCE is the key word. Remember how little you knew as a second year resident?!

I'm not talking about the PA or NP fresh out of school here. I'm talking about an pa/NP with years of Icu experience.

Let's not get ahead of ourselves here.

It's all about experience. And it applies to a variety of fields. If you HAD to choose between a CA-2 in September or a nurse anesthetist with 10 years experience (no attending in this hypothetical)... Who would You rather put u to sleep?
 
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The nursing critical care fellowship at Vanderbilt is spearheaded by an anesthesiologist. Go to the website and take a look at his CV. He now has a faculty appointment in the school of nursing, is a member of the National Organization of Nurse Faculties, and has presented at numerous scientific meetings for nurses.

http://www.mc.vanderbilt.edu/root/vumc.php?site=1anesthesiology&doc=32113



The best way to protect patients from the unsafe practice of medicine is to stop teaching non-physicians short-cuts to medical practice. Since the Medical Board does not have "legal" jurisdiction in defining nursing practice, I believe they have a moral responsibilty to protect patients by declaring that it is "unethical and unsafe for physicians to teach and encourage the practice of medicine by non-physicians." Violation of this regulation will be subjected to loss of medical privileges. It would be like me teaching my meat butcher to perform surgery. This is the best and possibly the only way to protect patients from Dr. Nurses and physicians who place personal gain above patient safety.
 

justaregularmed

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The nursing critical care fellowship at Vanderbilt is spearheaded by an anesthesiologist. Go to the website and take a look at his CV. He now has a faculty appointment in the school of nursing, is a member of the National Organization of Nurse Faculties, and has presented at numerous scientific meetings for nurses.

http://www.mc.vanderbilt.edu/root/vumc.php?site=1anesthesiology&doc=32113



The best way to protect patients from the unsafe practice of medicine is to stop teaching non-physicians short-cuts to medical practice. Since the Medical Board does not have "legal" jurisdiction in defining nursing practice, I believe they have a moral responsibilty to protect patients by declaring that it is "unethical and unsafe for physicians to teach and encourage the practice of medicine by non-physicians." Violation of this regulation will be subjected to loss of medical privileges. It would be like me teaching my meat butcher to perform surgery. This is the best and possibly the only way to protect patients from Dr. Nurses and physicians who place personal gain above patient safety.
Why would he quit he probably gets a kickback for starting the program, lol. $$$$
 

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well theres only one way to deal with this..... have the CNAs start a state nursing assistant board which regulates itself and expands their scope to include all RN duties ;)
a joke of course
 

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Am I getting a skewed perception of NPs here? I haven't run into a single NP that I can see taking on that kind of responsibility or even practicing independently. The NP students (I know, students, but still) I met on my OB/Gyn rotation had to look up the symptoms of PCOS... they had already been on that rotation for a month. They took no initiative. We got "student booklets" that mentioned Tindamax for BV - they didn't know what it was. They HAD the booklets for a MONTH and never bothered to look up the drug they didn't know. One of them (the oldest, who had been an RN for 20+ years) admitted she never really understood gram positive vs. gram negative bugs and doesn't know which are which. That one also thought chorionic villus sampling was done via peripheral blood draw -- so she obviously doesn't know what "chorion" means. More importantly, she wants to work in OB. None of the NP or PA students knew what a triple screen is. Another older NP student interviewed a patient with a complaint of vaginal pain and never asked when it started, if there was any itching or discharge, any dysuria, etc. These are students that are done with their pre-clinical education and are now on rotations. They will be able to practice independently in a matter of months.

I just don't get how we have these NP "residency" and "fellowship" programs popping up with the current dismal state of NP education. Are they only open to the very best of them? Do they need to have super high scores on whatever exams they take? Am I not seeing the type of students who wind up there? The thought of those students in critical care is SCARY.

I KNOW there's going to be a difference after they get 10 years of experience. But there's no law requiring physician supervision for the first 10 years, so...
 
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Stank811

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Jeez guys!

First of all.... We have to get with reality. There is a shortage of intensivists in the near future and we live in an era of work hour regulations. So we mUST work with midlevels.

That said my comment was meant as the following: an EXPERIENCED NP is much more capable of managing and dealing with critically sick patients compared to a bright eyed second year resident in July. Now one could argue.... Maybe there are some things a good third year surgery or anesthesia or medicine resident could do that may have an up on even an experiences NP. That's true. But on average, I think you are underestimating the ability of these midlevels once they gain experience. EXPERIENCE is the key word. Remember how little you knew as a second year resident?!

I'm not talking about the PA or NP fresh out of school here. I'm talking about an pa/NP with years of Icu experience.

Let's not get ahead of ourselves here.

It's all about experience. And it applies to a variety of fields. If you HAD to choose between a CA-2 in September or a nurse anesthetist with 10 years experience (no attending in this hypothetical)... Who would You rather put u to sleep?
As always this depends on the patient and the resident/midlevel....if we were picking out of a hat for both procedure and who was providing anesthesia there is no question that I will be picking out of the CA2 hat. Many CRNAs are not capable of doing any moderately complex case. Clearly my experience is quite difference than yours...at our program the majority of our CA-2s are better than our experienced CRNAs.

I agree that midlevels are not going anywhere but your comment that a DNP with a fellowship in CC will not try to independently run a "rural ICU" in the future is incredibly short sighted in my opinion. Yes...NP's are going to be an essential component of the future of CC delivery but to give them the political fire power of "fellowship training" is a terrible idea in the long run.

Europeman why do we need "fellowship" trained DNP's in the ICU. What was wrong with an acute care NP? What is gained with the "fellowship"?
 
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I thought the AMA was big with lobbying (?). Where do they stand on NPs and PAs?
 

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Jeez guys!

First of all.... We have to get with reality. There is a shortage of intensivists in the near future and we live in an era of work hour regulations. So we mUST work with midlevels.

That said my comment was meant as the following: an EXPERIENCED NP is much more capable of managing and dealing with critically sick patients compared to a bright eyed second year resident in July. Now one could argue.... Maybe there are some things a good third year surgery or anesthesia or medicine resident could do that may have an up on even an experiences NP. That's true. But on average, I think you are underestimating the ability of these midlevels once they gain experience. EXPERIENCE is the key word. Remember how little you knew as a second year resident?!

I'm not talking about the PA or NP fresh out of school here. I'm talking about an pa/NP with years of Icu experience.

Let's not get ahead of ourselves here.

It's all about experience. And it applies to a variety of fields. If you HAD to choose between a CA-2 in September or a nurse anesthetist with 10 years experience (no attending in this hypothetical)... Who would You rather put u to sleep?

experience helps, but it must be accompanied by knowledge, and any year resident has twice as much medical background/knowledge( USMLE`s, med school) as any NP out there( 2 y or RN Bull S.... learning to dress wounds and place IV lines and give med drips and then 2 years or "practitioner" stuff, brother pleaaaaaseeee!!!! ). :)
 

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I just disagree. I feel you are a bit ahead of yourselves and just don't really understand the training and capabilities of these midlevels
 

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I just disagree. I feel you are a bit ahead of yourselves and just don't really understand the training and capabilities of these midlevels
Have you worked with a mid level before?!?!
:)
it is mind blowing how incompetent/clueless they can be( with very very few exceptions).
 

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I just disagree. I feel you are a bit ahead of yourselves and just don't really understand the training and capabilities of these midlevels
BTW, there's a shortage of surgeons in rural america too. Are you going to advocate for letting midlevels get some extra training and be able to operate solo for "routine" cases?
 

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I just disagree. I feel you are a bit ahead of yourselves and just don't really understand the training and capabilities of these midlevels
Objectively, medical students, by the end of 3rd year, have more basic science training and several times the number of clinical hours of training than any NP/DNP program in the US currently offers. I've commented on this issue many times before and, if you'd like, I can PM you my side-by-side comparison of NP curricula with that of med school curricula.

Additionally, more and more evidence is coming out that prior experience as an RN (before pursuing an NP/DNP) is not as useful/significant as people originally thought -- this kind of confirms what many of us have thought: that working as a nurse doesn't automatically equate to thinking through a patient issue in a medical manner to come up with a differential. In fact, if you browse nursing message boards, a lot of nurses these days are using this as a way to justify direct-entry programs (where you become an NP/DNP within a few years with no prior healthcare experience at all -- the number of clinical hours of training required range from 500 - 1000ish and many programs do not provide preceptors; rather, they require the students to seek out preceptors themselves, thus providing clinical training of questionable quality). With all this being said, my question is, if you don't trust a newly-minted M4 to make any critical decisions, why do you think it's okay for someone with less training to do so?

Now, I realize you mentioned experienced NPs (by which, I'm assuming you mean those who have been practicing in a particular field for a number of years already), but the problem is, as far as I can tell, there's really nothing distinguishing the scope of practice between an experienced and a newly-graduated NP. Please feel free to correct me if I'm wrong. My personal opinion is that it's better to hire and work with PAs, who not only receive superior training compared to nursing midlevels, but also work together with physicians rather than claiming equivalence and fighting for independence.

Also, just wanted to clarify that I don't have anything against PAs. I think their curriculum is what NPs/DNPs should aspire to instead of focusing so much on nursing theory and other fluff courses that offer little clinical utility. If you're training to be a better clinician, your education should emphasize things like clinical utility, more clinical hours of training, etc. Not how to run a business or how to conduct research or how to influence health policy.
 
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MD Dreams

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BTW, there's a shortage of surgeons in rural america too. Are you going to advocate for letting midlevels get some extra training and be able to operate solo for "routine" cases?
Good point. I guarantee you that there are mid levels out there who would jump at the opportunity. There are a lot of specialties where we have shortages, for some reason only anesthesia seems to be the one getting shafted.

Shame on Vanderbilt and this Anesthesiologist who is putting this program together. It's because of scum like him that we are in this mess in the first place.
 

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I'm a future intensivist and I think this is a great idea. Lots of ICUs have NPs or PAs... This is just a formal way to get them trained for that role.

The best run. ICUs have NPs and an attending MD. The Icu with 2nd year residents and senior residents plus/minus fellow are more dangerous but obviously an inherent necessity of training.

Anyway.... Fact is there are not enough intensivists out there.... So I see nothing wrong with, for example, an in house NP running a unit with attending backup at home. It's sure better than having a second or third year resident in there with attending backup at home!

Now NPs will never, ever, independently run a unit without an MD.

You will be out of a job very soon. Once your NP/PA lobbies the State and Hospital to allow them unrestricted practice. You will be history. Don't worry about quality, etc, b/c you will have them trained very well. Good luck. Oh, and all the ICU RNs will back them and say they provide better care than you and they prefer working with them vs you. It is obvious you have no clue how the real world works.
 

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I'm going to take the other extreme, I don't want to work with residents or mid levels.

Normally I would have said residents hands down, but this new crop has a bunch of lazy people in it, I'm constantly saying they're at the level of 3rd year medical students to their PD.

Midlevels are frankly under trained and should only be used basically as note scribes. Now that being said, in theory a NP/PA can be quite good, as really any idiot can make it through medical school if they're persistant in their studies, and many Midlevels could have been docs, and can learn on the job. But I've had some humdinger interactions with Midlevels before.
 
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jdh71

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I'm going to take the other extreme, I don't want to work with residents or mid levels.

Normally I would have said residents hands down, but this new crop has a bunch of lazy people in it, I'm constantly saying they're at the level of 3rd year medical students to their PD.

Midlevels are frankly under trained and should only be used basically as note scribes. Now that being said, in theory a NP/PA can be quite good, as really any idiot can make it through medical school if they're persistant in their studies, and many Midlevels could have been docs, and can learn on the job. But I've had some humdinger interactions with Midlevels before.
My real experience with mid-levels in the ICU so far is an n=1, but it was positive. I think if I go PP, and I probably will, I may look at a mid-level for help with the clinical duties, especially the bull****.

I think that if you've got a smart mid-level - someone who is teachable - you can do a lot with them, provided YOU train them yourself.

Though, my experience with OTHER mid-levels has been HORRIBLE. The problem with mid-levels is that they cannot, will not, or simply have not the knowledge to think around many clinical issues. I think at the end of the day in many ways make more work, in a bad way, for the system than they contribute by helping in the manner that they do. If all they were doing was writing notes and processing discharges, we'd be fine, but they want to play at doctor, and the sincerely lack the training to do this properly. Hell, I remember coming out of residency and being like, "damn, that three years was seriously the BARE MINIMUM for trying to practice IM," so I have little respect for 500 clinical hours, which is nothing - like 6 weeks of residency time if my math is correct.

I don't know. Mostly I'd like to see them fill in the gaps - do the bull**** we don't want to or that take up too much of our time, but that's not what they largely want to do it seems - they want our jobs. I need someone writing notes, doing discharges, following up on labs and images, keeping track of pulmonary nodules, running down old images - that kind of things which would make anyone who is willing to do it worth their weight in gold, but that's not what they want to do.
 

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My real experience with mid-levels in the ICU so far is an n=1, but it was positive. I think if I go PP, and I probably will, I may look at a mid-level for help with the clinical duties, especially the bull****.

I think that if you've got a smart mid-level - someone who is teachable - you can do a lot with them, provided YOU train them yourself.

Though, my experience with OTHER mid-levels has been HORRIBLE. The problem with mid-levels is that they cannot, will not, or simply have not the knowledge to think around many clinical issues. I think at the end of the day in many ways make more work, in a bad way, for the system than they contribute by helping in the manner that they do. If all they were doing was writing notes and processing discharges, we'd be fine, but they want to play at doctor, and the sincerely lack the training to do this properly. Hell, I remember coming out of residency and being like, "damn, that three years was seriously the BARE MINIMUM for trying to practice IM," so I have little respect for 500 clinical hours, which is nothing - like 6 weeks of residency time if my math is correct.

I don't know. Mostly I'd like to see them fill in the gaps - do the bull**** we don't want to or that take up too much of our time, but that's not what they largely want to do it seems - they want our jobs. I need someone writing notes, doing discharges, following up on labs and images, keeping track of pulmonary nodules, running down old images - that kind of things which would make anyone who is willing to do it worth their weight in gold, but that's not what they want to do.
True that some of them can be very good, specially when they specialize in one particular area, and even then, they cant play docs, but can hold the fort for you for a while ( met an ortho and a cards np that way).
But in my experience the clueless have been way way more than the ok ones.
I you've worked on a va system, they think they are saving money by using np's as primary care, but it's the other way around with the "not following any guidelines even if it kills me, consult everybody, and go to er because I leave at 330 mentality".
That makes me want to bitch slap somebody! :)
 
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I think the goal of NP fellowships is to bridge the knowledge and clinical practice gaps after post-academic training which was recognized by their profession so they can become better providers in sub specialty areas such as done in the medical and other health care pprofessions. I commend them for developing more advanced clinically-based training programs than what they receive in their initial generalized NP school training. Just being an ICU RN for 20+ yrs doesn't translate into being an experienced ICU NP.

Since the goal of healthcare is to care for the patient, I think we need to embrace the interdisciplinary concept and focus on helping each other train to be the best provider and to use their best talents. I think trained ICU NPs realize their limitations and don't expect to practice independently. And regarding the "fluff nursing theory training", I know I much rather have the NP discuss with the patient or family sensitive case management topics than myself; their training excels ours on these topics.
 

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The problem is creating a fellowship which will allow them in the future to use political means to pass legislation to say they are equivalent and attempt to compete with physician providers and I guarantee they will. What is wrong with the standard masters degree? We as a medical community do not need more than that...unless you want to make a ton of money as a university running the program as Vandy is currently doing. You do not need a DNP with a fellowship to do your BS all you need is a NP. Just remember on the political level it is not physician vs nursing. It is physician vs nurses+PA+NP+DNP+CRNA+optometrist+chiropractors+podiatrist etc....they all want increasing scope and want to be paid the same as us and they are winning in the current political environment when you combine all their voices vs the physicians. Wake up ladies and gents...the govt, the hospitals, midlevel providers, insurance companies do not want us to have the power or the control of the money.
 

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And regarding the "fluff nursing theory training", I know I much rather have the NP discuss with the patient or family sensitive case management topics than myself; their training excels ours on these topics.
Explain. Seriously. Now. Explain what you mean by this. Go.
 

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Who cares. CCM will always need a team of solid practitioners and nurses fit right in. A good ICU nurse who goes CCM NP would be invaluable. My unit nurses are the bomb.

Interventional pulm and pulm in general is where ill be dedicating a good portion of my time. Sleep and pulm keep the bills paid.
 

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Explain. Seriously. Now. Explain what you mean by this. Go.
Right on man.

For the OP: Thats the most ridiculous thing ive ever heard a physician say. WTF kind of doctor in the ICU setting cant handle talking with families. Its a necessity on these patients. ESPECIALLY on these patients. Thats where the rubber meets the road man. ESTABLISHING GOALS of CARE should be second nature to a CCM doc.
 

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Interventional? So many peocedures. Insane ones.
Not likely....... I've posted my thoughts on the issue in the Pccm fellowship thread. Even IF you over ce the difficulties in setting something up for yourself afterwards to do interventional, most of those procedures don't reimburse much more (if at all) than a base 31622 diagnostic bronch.

And yes insane.....i agree, but not in the way you meant I'm sure.
 
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I work at a major teaching hospital in a lowly role; however, I ran into a nice Nurse Practitioner who worked in a NICU. I was talking to her about her job and she filled me in on her shift; admits, orders, run codes etc. She was very open to discussing her career field and venue so I asked her some specific questions about intensivist physician roles...

long story short she interrupted me and said "I'll just tell you about what I do because I'm basically an intensivist".

I found this confusing as she was a NP (although likely experienced as she was advanced in age). In practical terms - is there much of a difference between a NP who works in a NICU vs a CC/Pulm physician that works in a NICU? Is it true that this NP is effectively an intensivist?
 

jdh71

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I work at a major teaching hospital in a lowly role; however, I ran into a nice Nurse Practitioner who worked in a NICU. I was talking to her about her job and she filled me in on her shift; admits, orders, run codes etc. She was very open to discussing her career field and venue so I asked her some specific questions about intensivist physician roles...

long story short she interrupted me and said "I'll just tell you about what I do because I'm basically an intensivist".

I found this confusing as she was a NP (although likely experienced as she was advanced in age). In practical terms - is there much of a difference between a NP who works in a NICU vs a CC/Pulm physician that works in a NICU? Is it true that this NP is effectively an intensivist?
Depends on how loosely you want to define that term.

Experience does go a long way, but the difference in education and training is light years different. I think to get an NP you need like a few hundred clinical hours, and at most places it's a masters level academic degree that requires 18 to 24 more months (mostly classroom work) after a BSN (4 yr degree) and some work experience as an RN. The MD has 4 years of medical school past his undergraduate degree, and then three more years of post-graduate medical training, and three more years of neonatology (pulm/crit is an ADULT specialty, this can be a bit confusing from the outside), which is a specialty that focuses just on the critical care of little babies. There isn't even a comparison in education and training levels between the two. Though, on a day to day basis both would do very similar things. One is an expert and the other is someone who "does stuff" in the field.
 

Pneumothorax

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I am very curious about this topic because it really seems to be a hot button issue. I notice that a lot of people denounce midlevel providers for being unable to provide quality care in the very same paragraph that they talk about midlevels taking their jobs. Basically, you cannot be an MD and comment on this topic without having a built in conflict of interest.

What I am really interested in is some solid data. Has anyone ever done a study generally about midlevel providers and patient outcomes? I realize that midlevels in ICU settings are so rare that a good study may not be possible, but I'm sure there is real evidence out there and that's where I should look to form my opinion.

I've worked with a few mid levels during medical school rotations. Some of them have really impressed me as being super smart and capable, and I have thought some of them to have mammary tissue where neurons are supposed to be. But my sample size isn't large enough to generalize, and I suspect that no one here has the proper sample size.
 

badasshairday

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What I am really interested in is some solid data. Has anyone ever done a study generally about midlevel providers and patient outcomes?
I've seen studies comparing the roles of 1) PA/NP's in the ICU with 2) residents. Showed PA/NP's were non-inferior. Obviously both groups were headed by Attending Physicians.

You will never see a study with Midlevel's only compared to Attending's only because hospital ethics committees just would not allow it.
 

ssg

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I've seen studies comparing the roles of 1) PA/NP's in the ICU with 2) residents. Showed PA/NP's were non-inferior. Obviously both groups were headed by Attending Physicians.
You will never see a study with Midlevel's only compared to Attending's only because hospital ethics committees just would not allow it.
Hi, can you reference this please? I can say as a resident, I had to spend some time with a NP practicing independently. Even at that time as a second year resident, I was able to observe her doing some dumb dumb things with her patients. They do not follow guidelines, probably don't even know they exist.

As for CCM, I am very surprised at the openness to midlevels given the dense physiology that is the foundation of critical care medicine. It seems like it is all numbers to the ICU RNs and midlevels, but there is a method to the madness. I would never want to be cared for by a critical care NP. And, yes I would want to be cared for by residents and fellows, because they would actually understand my disease process.

I think we often forget our own training and what we went through to become physicians. We should continue supporting the education of residents and medical students if you want to relieve the physician shortage, rather than training midlevels. Physicians are awful lobbyists and we need to get our act together before we diminish.
 

cbrons

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Jeez guys!

First of all.... We have to get with reality. There is a shortage of intensivists in the near future and we live in an era of work hour regulations. So we mUST work with midlevels.

That said my comment was meant as the following: an EXPERIENCED NP is much more capable of managing and dealing with critically sick patients compared to a bright eyed second year resident in July. Now one could argue.... Maybe there are some things a good third year surgery or anesthesia or medicine resident could do that may have an up on even an experiences NP. That's true. But on average, I think you are underestimating the ability of these midlevels once they gain experience. EXPERIENCE is the key word. Remember how little you knew as a second year resident?!

I'm not talking about the PA or NP fresh out of school here. I'm talking about an pa/NP with years of Icu experience.

Let's not get ahead of ourselves here.

It's all about experience. And it applies to a variety of fields. If you HAD to choose between a CA-2 in September or a nurse anesthetist with 10 years experience (no attending in this hypothetical)... Who would You rather put u to sleep?

Ill take a 2nd yr resident over someone with a fake medical degree anyday

Am I getting a skewed perception of NPs here? I haven't run into a single NP that I can see taking on that kind of responsibility or even practicing independently. The NP students (I know, students, but still) I met on my OB/Gyn rotation had to look up the symptoms of PCOS... they had already been on that rotation for a month. They took no initiative. We got "student booklets" that mentioned Tindamax for BV - they didn't know what it was. They HAD the booklets for a MONTH and never bothered to look up the drug they didn't know. One of them (the oldest, who had been an RN for 20+ years) admitted she never really understood gram positive vs. gram negative bugs and doesn't know which are which. That one also thought chorionic villus sampling was done via peripheral blood draw -- so she obviously doesn't know what "chorion" means. More importantly, she wants to work in OB. None of the NP or PA students knew what a triple screen is. Another older NP student interviewed a patient with a complaint of vaginal pain and never asked when it started, if there was any itching or discharge, any dysuria, etc. These are students that are done with their pre-clinical education and are now on rotations. They will be able to practice independently in a matter of months.

I just don't get how we have these NP "residency" and "fellowship" programs popping up with the current dismal state of NP education. Are they only open to the very best of them? Do they need to have super high scores on whatever exams they take? Am I not seeing the type of students who wind up there? The thought of those students in critical care is SCARY.

I KNOW there's going to be a difference after they get 10 years of experience. But there's no law requiring physician supervision for the first 10 years, so...
ROfl....You gotta be kidding me... You have to laugh to keep from crying.

experience helps, but it must be accompanied by knowledge, and any year resident has twice as much medical background/knowledge( USMLE`s, med school) as any NP out there( 2 y or RN Bull S.... learning to dress wounds and place IV lines and give med drips and then 2 years or "practitioner" stuff, brother pleaaaaaseeee!!!! ). :)
DNP programs are apparently cheap, and the nursing org helps universities who start them up a lot. I had a university president pointblank tell me this 2 years ago. Now there are people who see it as a viable shortcut to playing doctor.

Objectively, medical students, by the end of 3rd year, have more basic science training and several times the number of clinical hours of training than any NP/DNP program in the US currently offers. I've commented on this issue many times before and, if you'd like, I can PM you my side-by-side comparison of NP curricula with that of med school curricula.

Additionally, more and more evidence is coming out that prior experience as an RN (before pursuing an NP/DNP) is not as useful/significant as people originally thought -- this kind of confirms what many of us have thought: that working as a nurse doesn't automatically equate to thinking through a patient issue in a medical manner to come up with a differential. In fact, if you browse nursing message boards, a lot of nurses these days are using this as a way to justify direct-entry programs (where you become an NP/DNP within a few years with no prior healthcare experience at all -- the number of clinical hours of training required range from 500 - 1000ish and many programs do not provide preceptors; rather, they require the students to seek out preceptors themselves, thus providing clinical training of questionable quality). With all this being said, my question is, if you don't trust a newly-minted M4 to make any critical decisions, why do you think it's okay for someone with less training to do so?

Now, I realize you mentioned experienced NPs (by which, I'm assuming you mean those who have been practicing in a particular field for a number of years already), but the problem is, as far as I can tell, there's really nothing distinguishing the scope of practice between an experienced and a newly-graduated NP. Please feel free to correct me if I'm wrong. My personal opinion is that it's better to hire and work with PAs, who not only receive superior training compared to nursing midlevels, but also work together with physicians rather than claiming equivalence and fighting for independence.

Also, just wanted to clarify that I don't have anything against PAs. I think their curriculum is what NPs/DNPs should aspire to instead of focusing so much on nursing theory and other fluff courses that offer little clinical utility. If you're training to be a better clinician, your education should emphasize things like clinical utility, more clinical hours of training, etc. Not how to run a business or how to conduct research or how to influence health policy.
Prior experience as a nurse means jack. Most nurses dont even have a rudimentary understanding of basic human anatomy and physiology.
I think the goal of NP fellowships is to bridge the knowledge and clinical practice gaps after post-academic training which was recognized by their profession so they can become better providers in sub specialty areas such as done in the medical and other health care pprofessions. I commend them for developing more advanced clinically-based training programs than what they receive in their initial generalized NP school training. Just being an ICU RN for 20+ yrs doesn't translate into being an experienced ICU NP.

Since the goal of healthcare is to care for the patient, I think we need to embrace the interdisciplinary concept and focus on helping each other train to be the best provider and to use their best talents. I think trained ICU NPs realize their limitations and don't expect to practice independently. And regarding the "fluff nursing theory training", I know I much rather have the NP discuss with the patient or family sensitive case management topics than myself; their training excels ours on these topics.
So because nurses take classes on how to be sensitive already they are better at relating to patients? The kind nurse, the neurotic, antisocial doctor? Way to promote the stereotype. Its a bunch of rubbish.
 
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Sometimes on a Sunday morning I'll throw the football around in the backyard with my brother, often I say to myself, "I'm basically doing the same thing as Tom Brady". But for some weird reason I don't get paid nearly as much he does...go figure.
 

dotcb

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Sorry - nurses should not ever refer to themselves as "attending" or "intensivist." 1 means you did a residency after medical school, the other means you did a fellowship after that. Nurses do neither. Personally, I also think they shouldn't wear long white coats, but along with PT's, speech therapists, and administrators, that symbol has clearly lost its meaning too. (And no - I don't wear a white coat.)
 

MTGas2B

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Sorry - nurses should not ever refer to themselves as "attending" or "intensivist." 1 means you did a residency after medical school, the other means you did a fellowship after that. Nurses do neither. Personally, I also think they shouldn't wear long white coats, but along with PT's, speech therapists, and administrators, that symbol has clearly lost its meaning too. (And no - I don't wear a white coat.)
They could be referred to as CRNI. And then we could be referred to as MDI, not to be confused with inhalers.


On the iPhone
 

BuckRx

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So could I hypothetically graduate high school, do a 2 yr RN, 2 yr NP, 1 yr fellowship and become a 23 year old nurse intensivist?
 

emedpa

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So could I hypothetically graduate high school, do a 2 yr RN, 2 yr NP, 1 yr fellowship and become a 23 year old nurse intensivist?
nope, you need a min of a bsn to get into np, 2 yrs for np(msn), 1 yr for fellowship so 25 yr old...
 
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we have it from their own mouths that they don't think hospitalists with 1 year of cc fellowship is adequate, how would they explain why a np would be
Don't know. I'm an RN myself and have doubts about mid-levels all the time (For the record, I'm in agreement with most other posters here who state PA training is vastly superior to NP training). I'm not advocating mid-levelers practicing independently or running CC units alone, both kind of scare me.

However, they (mostly NP's) have the momentum and the support from higher ups (hospital and government), and it would be one hell of a train to stop.