We Choose NPs

Started by Alvarez13
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Literally the role of any strong ED mid-level should be to appropriately disposition ESI level 4s with minimal to moderate supervision (not even including ESI level 5s here because an MS3 should be able to do that independently) and intelligently present ESI level 3s and SOME 2s to the attending.

The problem is the ones I've seen can BARELY do the 4s and often mess them up pretty good.
 
Boatswain2PA said:
You may not practice or run your ED the way you project yourself here, but if you do then YOU could be the reason your MLPs suck.

I'm pretty damn good at what I do, and the BC EPs I work PRN with are constantly wanting me to come on full time in that shop.

But I wouldnt work more than one shift with someone with the attitude you present here. Want me to sit on your finger and be your bitch-boy? I'll leave a little present on your scrubs as I fly away, leaving you to hire another new grad NP. Good luck with that.
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When I give you shining example of how "optimal team practice" can't even be handled by them, then its not "my fault" that the MLP can't enter orders correctly, even if he WROTE THEM DOWN as I gave them to them.

... and we've had this talk before; as long as I have to defend your care and sign your charts... then you do as I tell you to do.
 
Your entitled to your opinion, and leadership style.

You are also entitled to suffer the consequences of them, including the inability to attract good help.

Why do you stay at a shop where you have no control over such incompetence?
 
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RustedFox said:
I had a dream once where I did this because I wanted to "guess the dimer".
Then I woke up and realized how stupid and pointless that would be.
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I play lots of stupid games in the ED. We play Guess The:
- EtOh Level
- potassium level in like ESRD pts with EKG changes
- HCO3- in DKA
- Lactates for the super sick septic patients
- Head CTs in acute TBI

I play mostly with nurses. Especially the hot ones.

Advanced players of this game, which requires months of practicing, will play Guess The:
- number of rib fractures
- HCG levels
- the specific kind of hip fracture (sub cap, fem neck, intertroch, etc)
- BNP
- QRS or QTC for select toxic ingestions.
 
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Boatswain2PA said:
Your entitled to your opinion, and leadership style.

You are also entitled to suffer the consequences of them, including the inability to attract good help.

Why do you stay at a shop where you have no control over such incompetence?
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Physicians have no control in probably 80% of practice environments today. You talk a lot about us being the “leaders” but that battle was lost a while ago so we are left with
1. Forced supervision of midlevels that likely don’t make us extra money (make the suits money)
2. Extra liability for people we really don’t have a reasonable chance to train, hire or fire
3. Midlevels that fall in 3 categories- incompetent, overconfident, or rarely (as you frequently proclaim in your own case) clinically good (but then see #1/2- an “amazing” midlevel still doubles my liability because I’m responsible for my patients AND theirs while not making me money)

It’s easy to say leave a job like that—- but if 80% of jobs are like that it’s hard to find a rare one where the docs actually can easily fire an underperforming PA/ NP without major blowback.

Regarding someone like you “leaving” because you don’t want to follow orders — I’m sure no one will care. Even a clinically excellent doctor today is just a cog in the wheel for the suits. They just want a human billing machine to move the patients and enter the codes. No one will shed a single tear. Which again is the problem - no one (with power) cares for clinical excellence which is part of the reason no one cares about the skill differences between PA 1, PA 2, NP 3 or the skill difference between a physician and a midlevel as long as the machine still spits out money.
 
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Boatswain2PA said:
Your entitled to your opinion, and leadership style.

You are also entitled to suffer the consequences of them, including the inability to attract good help.

Why do you stay at a shop where you have no control over such incompetence?
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Why don’t you just go to medical school?
 
doctalaughs said:
Physicians have no control in probably 80% of practice environments today. You talk a lot about us being the “leaders” but that battle was lost a while ago so we are left with
1. Forced supervision of midlevels that likely don’t make us extra money (make the suits money)
2. Extra liability for people we really don’t have a reasonable chance to train, hire or fire
3. Midlevels that fall in 3 categories- incompetent, overconfident, or rarely (as you frequently proclaim in your own case) clinically good (but then see #1/2- an “amazing” midlevel still doubles my liability because I’m responsible for my patients AND theirs while not making me money)

It’s easy to say leave a job like that—- but if 80% of jobs are like that it’s hard to find a rare one where the docs actually can easily fire an underperforming PA/ NP without major blowback.

Regarding someone like you “leaving” because you don’t want to follow orders — I’m sure no one will care. Even a clinically excellent doctor today is just a cog in the wheel for the suits. They just want a human billing machine to move the patients and enter the codes. No one will shed a single tear. Which again is the problem - no one (with power) cares for clinical excellence which is part of the reason no one cares about the skill differences between PA 1, PA 2, NP 3 or the skill difference between a physician and a midlevel as long as the machine still spits out money.
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Very well put. Like everyone else, I dont have a solution to these problems. I understand why some docs, and (for different reasons) some MLPs want independence, but I dont think that's the "right" solution either as there is simply too much variability between us (meaning a lot of us suck, and need close supervision).

While docs no longer have the positional authority they once had, there is always room for individual leadership and mentoring. Yeah, I get it, some say "it's not my job to train MLPs", but I guess it IS now part if your job. Or, it is if you want good ones.
 
Keep in mind many of the docs on here don't get a choice in the MLPs. the CMGs tell them what to do. Don't do it then you can't work there. FWIW I strongly prefer PA to NP.

Reality is many NPs especially are not terribly good and have zero critical thinking skills. My SDG has MLPs who understand who cuts their checks.

We recently took over a shop With one fairly poorly performing MLP. warning has been given. unsure if you can teach an old dog new tricks.

One of our other new MLPs is really smart good and eager. I got some of the notes sent to me as a supervising MD. Holy cow.. they got a 4 page email and 3 follow ups about how terrible the notes were. Like 0 MDM. no differential. like apparently the CMG she used to work for never bothered teaching people how to do a chart.
 
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Well thankfully we won't have to worry about them being poorly trained too much longer. Welcome to the new era of ENP...

wset.com

Averett becomes first school in state to offer Emergency Nursing Practitioner program

DANVILLE, Va. (WSET) -- Averett University now has the first Emergency Nursing Practitioner Program in all of Virginia. This could help get your the best care in a life or death situation. The program is only available in nine states. The practical training will help meet the growing need for...
wset.com wset.com
 
No one bothered to edit that piece of journalism. And they completely misunderstand why wait times are 3-4 hours.
emletters said:
Well thankfully we won't have to worry about them being poorly trained too much longer. Welcome to the new era of ENP...

wset.com

Averett becomes first school in state to offer Emergency Nursing Practitioner program

DANVILLE, Va. (WSET) -- Averett University now has the first Emergency Nursing Practitioner Program in all of Virginia. This could help get your the best care in a life or death situation. The program is only available in nine states. The practical training will help meet the growing need for...
wset.com wset.com
Click to expand...
 
TooMuchResearch said:
To quote a nurse I know who is now in NP school. "Holy **** they're not teaching us anything. Why would anyone let us practice independently?"
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You're saying that the essays they write as if taking an English class doesn't teach them patient care?

One of my friends who is in NP school, her homework is so dumb, yet she struggles with it. I don't think she knows any real medicine because she's either been an OB or a psych nurse. Now she's considering going into family medicine or urgent Care. Pretty sure those fields require some basic medical knowledge.
 
Not anymore. We choose NP.
cyanide12345678 said:
You're saying that the essays they write as if taking an English class doesn't teach them patient care?

One of my friends who is in NP school, her homework is so dumb, yet she struggles with it. I don't think she knows any real medicine because she's either been an OB or a psych nurse. Now she's considering going into family medicine or urgent Care. Pretty sure those fields require some basic medical knowledge.
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Join AAEM if you haven't yet.
 
NurWollen said:
I don't like the 'units' comparison because chiropractors and naturopaths use similar (albeit fraudulent) charts to make their education look equivalent to ours.
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Whenever people bring up "equal education" because "units" or "classes" are the same, I just always use the same example to debunk that:

"Just because two classes are named the same thing doesn't mean they equally go into depth or are as intense/challenging. Often students take very similar classes in high school as they do in undergrad. Just because 9th grade "Biology I" is called "Biology I" doesn't mean it's going to be as intellectually demanding/deep as the "Bio I" taught in freshmen year of undergrad"

Not to mention the actual knowledge needed within real practice. Chiropractors probably learn just as in depth Neuro-physiology as us, but honestly unless they're specifically doing research or are in academics, since they don't actually do anything in clinical practice to modulate the normal physiology of the nervous system (They just try to make whats normal more normal through manipulation) they don't have any reason to actually remember the steps of a nerve conduction for example. They just need to know what adjustment could be done to make the normal physiology happen. Unlike physicians who actually prescribe drugs to alter this physiology and therefore must understand pertinent parts of the system.
 
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KeikoTanaka said:
Not to mention the actual knowledge needed within real practice. Chiropractors probably learn just as in depth Neuro-physiology as us, but honestly unless they're specifically doing research or are in academics, since they don't actually do anything in clinical practice to modulate the normal physiology of the nervous system (They just try to make whats normal more normal through manipulation) they don't have any reason to actually remember the steps of a nerve conduction for example. They just need to know what adjustment could be done to make the normal physiology happen. Unlike physicians who actually prescribe drugs to alter this physiology and therefore must understand pertinent parts of the system.
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Actually they learn a bunch of mostly junk pseudo-science with a bit of real anatomy thrown in. They don't make things "more normal". They give placebo massages that make people feel better, without (hopefully) changing the alignment of vertebrae. If they could actually do manipulation that could change anatomy, we'd likely have scores of people leaving chiropractic clinics parpaplegic or quadraplegic. Any time I see one of these quacks address themselves as "doctor" it makes my blood boil. Might as well go to a Haitian Shaman and have him read the entrails.....
 
GeneralVeers said:
Actually they learn a bunch of mostly junk pseudo-science with a bit of real anatomy thrown in. They don't make things "more normal". They give placebo massages that make people feel better, without (hopefully) changing the alignment of vertebrae. If they could actually do manipulation that could change anatomy, we'd likely have scores of people leaving chiropractic clinics parpaplegic or quadraplegic. Any time I see one of these quacks address themselves as "doctor" it makes my blood boil. Might as well go to a Haitian Shaman and have him read the entrails.....
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This. I used to just quietly roll my eyes when a patient would mention going to their chiropractor. Now, I've seen multiple vertebral art dissections after cervical spinal "manipulations," one of whom I knew personally. I now tell every single one of these people that chiropractors are a bunch of quacks at best, and assassins at worst and that I am strongly recommending in no uncertain terms that they never go back.
 
Alvarez13 said:
www.texmed.org

Midlevel Practitioners Work For Physicians; Here’s Why

www.texmed.org www.texmed.org

Maybe I should reconsider moving to TX.
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I read that statement that you linked, and I don't see a negative. That is the whole point of NPs, especially in the office. A PCP can increase their panel by 40% with an NP, and that is supervision immediately right there.

Unless you were not planning to move to TX (passive), and that you had already ruled it out in the past (active), and this now might make you want to move there. Using "reconsider" is what hung me up.
 
Embarrassing thread for the primary posters...what...you're trying to out do each other on how much smarter you are than nurses? You might be surprised at the surgeons comments about you guys when you hang up the phone after interrupting them in the OR. And you ARE doctors...
 
Teillard said:
Embarrassing thread for the primary posters...what...you're trying to out do each other on how much smarter you are than nurses? You might be surprised at the surgeons comments about you guys when you hang up the phone after interrupting them in the OR. And you ARE doctors...
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Oh NO not the surgeon! We couldn’t care less what a surgeon says after they hang up I’m seeing the next patient and placing their words in the chart.

Also the whole point of training as an physician is to be a physician mid level providers do not have the knowledge of a physician.
 
Teillard said:
Embarrassing thread for the primary posters...what...you're trying to out do each other on how much smarter you are than nurses? You might be surprised at the surgeons comments about you guys when you hang up the phone after interrupting them in the OR. And you ARE doctors...
Click to expand...

I don't give a crap. They are PAID to be on-call, and I can call them up to chat about the weather if I like. They are required to call me back.

You should hear the things I say about surgeons when their poorly managed post-op patients show up in my ED......
 
GeneralVeers said:
I don't give a crap. They are PAID to be on-call, and I can call them up to chat about the weather if I like. They are required to call me back.
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Then I suspect the mid levels might say something along the same lines as that about you guys. See how this whole circle jerk thing works? You're smarter than the nurses..happy now?

Look...I get the benefits of venting on forums like these about people that drive you nuts, but in the end it just contributes to a hole in your stomach lining and does nothing for patients. What you need to do, you need to do off line. These types of forum gripings leads to hostility and toxicity and while I don't expect to see some physician shoot a bunch of nurses, the mentality does lead to what we see in Ohio, Texas and California.

So just knock it off, ok? The internet is not your friend here.
 
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Teillard said:
Then I suspect the mid levels might say something along the same lines as that about you guys. See how this whole circle jerk thing works? You're smarter than the nurses..happy now?

Look...I get the benefits of venting on forums like these about people that drive you nuts, but in the end it just contributes to a hole in your stomach lining and does nothing for patients. What you need to do, you need to do off line. These types of forum gripings leads to hostility and toxicity and while I don't expect to see some physician shoot a bunch of nurses, the mentality does lead to what we see in Ohio, Texas and California.

So just knock it off, ok? The internet is not your friend here.
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Are you seriously trying to tell us that venting online about midlevels leads to mass shootings?
 
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The point is nurses aren't doctors. I don't give many ****s about what another doctor says about me after they hang up the phone.
Teillard said:
Embarrassing thread for the primary posters...what...you're trying to out do each other on how much smarter you are than nurses? You might be surprised at the surgeons comments about you guys when you hang up the phone after interrupting them in the OR. And you ARE doctors...
Click to expand...
 
Teillard said:
Then I suspect the mid levels might say something along the same lines as that about you guys. See how this whole circle jerk thing works? You're smarter than the nurses..happy now?

Look...I get the benefits of venting on forums like these about people that drive you nuts, but in the end it just contributes to a hole in your stomach lining and does nothing for patients. What you need to do, you need to do off line. These types of forum gripings leads to hostility and toxicity and while I don't expect to see some physician shoot a bunch of nurses, the mentality does lead to what we see in Ohio, Texas and California.

So just knock it off, ok? The internet is not your friend here.
Click to expand...
275211
 
Teillard said:
Then I suspect the mid levels might say something along the same lines as that about you guys. See how this whole circle jerk thing works? You're smarter than the nurses..happy now?

Look...I get the benefits of venting on forums like these about people that drive you nuts, but in the end it just contributes to a hole in your stomach lining and does nothing for patients. What you need to do, you need to do off line. These types of forum gripings leads to hostility and toxicity and while I don't expect to see some physician shoot a bunch of nurses, the mentality does lead to what we see in Ohio, Texas and California.

So just knock it off, ok? The internet is not your friend here.
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Hahahaha wtf

Thanks for the wake up call CRNA
 
Teillard said:
Then I suspect the mid levels might say something along the same lines as that about you guys. See how this whole circle jerk thing works? You're smarter than the nurses..happy now?

Look...I get the benefits of venting on forums like these about people that drive you nuts, but in the end it just contributes to a hole in your stomach lining and does nothing for patients. What you need to do, you need to do off line. These types of forum gripings leads to hostility and toxicity and while I don't expect to see some physician shoot a bunch of nurses, the mentality does lead to what we see in Ohio, Texas and California.

So just knock it off, ok? The internet is not your friend here.
Click to expand...
That’s an absurd premise
 
Teillard said:
...These types of forum gripings leads to hostility and toxicity and while I don't expect to see some physician shoot a bunch of nurses, the mentality does lead to what we see in Ohio, Texas and California.

So just knock it off, ok? The internet is not your friend here.
Click to expand...

Guys, the internet police are here!

You must be lots of fun at work...
 
Man this thread took a turn for the worse when the non-physicians got involved.

Couldn't care less about what people say behind my back after I consult them - I make more money than they do and spent half my shifts last month playing computer games and watching netflix.
 
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No other country in the world relies so heavily on midlevels with far less training than a doctor. Somehow they spend far less money, yet still maintain a fairly rigorous level of medical training.

We do a ton of unnecessary stuff and then say “oh look we have a huge shortage!!! There’s no way doctors can take care of us all!! let’s recruit the 2-year online degree folks to do our healthcare.” Geez- talk about stupid.
 
doctalaughs said:
No other country in the world relies so heavily on midlevels with far less training than a doctor. Somehow they spend far less money, yet still maintain a fairly rigorous level of medical training.

We do a ton of unnecessary stuff and then say “oh look we have a huge shortage!!! There’s no way doctors can take care of us all!! let’s recruit the 2-year online degree folks to do our healthcare.” Geez- talk about stupid.
Click to expand...

Blame Americans who want everything NOW. They want to be seen in less than 30 minutes, want an office visit quickly, and want a surgical procedure tomorrow. The rest of the world is okay waiting for stuff. That's why multi-hour waits in the ER-waiting room are standard in Canada and the UK, and waits for office visits can span months. I much prefer the American system, much for my own health care and my career, but it simply reflects a huge cultural difference of which most people involved in policy can't grasp.
 
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I think 20% of the nurses in my ER are now NP's. We have one that does a full assessment instead of a nursing assessment, which I think is going to create a legal situation. She documented a GU exam "no gross blood" and could not grasp that you can't do that without examining the patient. She said she didn't see any gross blood on his jeans so that counted. No, not quite. Not quite at all. Not sure if there is a job market for all the NP's in my area. So a lot of them will continue to work as RN's but with NP titles.
 
GeneralVeers said:
Blame Americans who want everything NOW. They want to be seen in less than 30 minutes, want an office visit quickly, and want a surgical procedure tomorrow. The rest of the world is okay waiting for stuff. That's why multi-hour waits in the ER-waiting room are standard in Canada and the UK, and waits for office visits can span months. I much prefer the American system, much for my own health care and my career, but it simply reflects a huge cultural difference of which most people involved in policy can't grasp.
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That’s true and fine to want quick care but it should be connected to payment. Want to be seen twice as fast- pay more privately. Want to wait? - be on basic govt healthcare.

But also cultural perceptions in America that people should never have any pain, should go in for self-limited stuff (because it’s free) and basically get surgery x and intervention y/z even though they are morbidly obese /terminally ill/ destroyed their organs thru drugs etc. are almost impossible to change.

America has to say no - we aren’t doing your knee replacements if your BMI is 50, we aren’t keeping you on a ventilator when your chances are zero and we aren’t doing anything invasive once you hit a certain combination of age/ state of health. And we are aren’t doing interventions that have dubious/zero evidence. That is.... unless you pay personally - then decide whatever you want.

If we were able to do all these smart things we wouldn’t need a single midlevel in this country and could take care of our entire population with doctors that actually were fully trained.

Instead we’ll limp along with quarter-trained providers pretending to take “great care of patients with a team model” while milking every last penny out of our economy and satisfying the masses stupidest impulses.
 
doctalaughs said:
That’s true and fine to want quick care but it should be connected to payment. Want to be seen twice as fast- pay more privately. Want to wait? - be on basic govt healthcare.
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Agree completely. I like the public/private hospital system in Australia. A good compromise if we MUST have some for of public care. Unfortunately we've mixed the two in this country and have to give the same care to everyone.

But also cultural perceptions in America that people should never have any pain, should go in for self-limited stuff (because it’s free) and basically get surgery x and intervention y/z even though they are morbidly obese /terminally ill/ destroyed their organs thru drugs etc. are almost impossible to change.
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Agreed. We are culturally different and we aren't going to change any time soon. The Medicare For All people need to realize this.

America has to say no - we aren’t doing your knee replacements if your BMI is 50, we aren’t keeping you on a ventilator when your chances are zero and we aren’t doing anything invasive once you hit a certain combination of age/ state of health. And we are aren’t doing interventions that have dubious/zero evidence. That is.... unless you pay personally - then decide whatever you want.
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Yes of course. This single change would save us billions......it will also never happen.
 
doctalaughs said:
No other country in the world relies so heavily on midlevels with far less training than a doctor. Somehow they spend far less money, yet still maintain a fairly rigorous level of medical training.

We do a ton of unnecessary stuff and then say “oh look we have a huge shortage!!! There’s no way doctors can take care of us all!! let’s recruit the 2-year online degree folks to do our healthcare.” Geez- talk about stupid.
Click to expand...

Other countries haven't created an artificial shortage of physicians like the US has. Also in other countries, it takes a lot less time to become a physician. Just looking at anesthesia, are there even enough MDs to provide enough anesthesia to everyone in the US? Enough MDs to see all ER patients? PCP? Specialty? And it's not like the midlevels are stuffing their own pockets, it's usually administration or owner MD who benefits the most financially.
 
allantois said:
Other countries haven't created an artificial shortage of physicians like the US has. Also in other countries, it takes a lot less time to become a physician. Just looking at anesthesia, are there even enough MDs to provide enough anesthesia to everyone in the US? Enough MDs to see all ER patients? PCP? Specialty? And it's not like the midlevels are stuffing their own pockets, it's usually administration or owner MD who benefits the most financially.
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Yes, that's why we don't have the same number of physicians per population as the UK, S. Korea, Japan, and Canada.
 
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