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There is no shortage of physicians.
There is a shortage of rural locales that are willing to pay for physicians to provide services there.
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There is a shortage of rural locales that are willing to pay for physicians to provide services there.
This isn't quite true. While the didactic portion of education is shorter in most countries (5 years integrated vs 8 years of med school and undergrad) postgraduate training tends to be considerably longer outside of north america.
As for the physician shortage - that "shortage" has always been more of a distribution issue than an actual numerical shortage. Physicians in the US are generally less inclined to live and work in rural and urban poor areas and are heavily disincentivised to do primary care. Even if we made more MDs it wouldn't change where they would seek to live and what fields they would apply and train in.
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Don't get me wrong, I'd love for both of those to happen.
But...
The money in primary care isn't all that bad in truth. Most of the FPs in my group who have been here at least 2 years are pulling in 250k+, several are over 300. That's not what you EPs are making, but for bankers hours with no nights/weekends/holidays its not too shabby.
As for paperwork, if you're doing more than signing stuff you haven't trained your staff well enough.
I was actually shocked at what some of our PCPs are pulling locally. I've heard that some of our high producers at a local clinic are pulling over 400K. 100% outpatient. I'm not sure how many patients they are seeing daily but I was impressed. I'm not sure if it's a regional thing down here in the South or if salaries are rising across the board for PCPs. I hope it's the latter as we really need to provide a better incentive for med students to pursue primary care. I can't count how many patents I get in the ED that are there not for an emergent condition but because they can't get in to see anyone and wait lists are out 2-3+ months.
Need 30+ to pull that off, but it's doable.
D
deleted109597
Thank you all for bringing it back to the original topic. Man did that get out of line quick.
My PA with 20 years of experience has made some decisions that made me very uncomfortable. And I just started my career and already I've seen such huge mistakes in the handful of shifts I've done.
PAs still go to a real school. I can't imagine what things would have been like working with a NP who went to an online school.
PAs still go to a real school. I can't imagine what things would have been like working with a NP who went to an online school.
Reel them in. It's your license over their feels.
My shop is doing JUST THIS right now.
It was like making roster cuts for varsity sports.
You did allude "Change is coming" in another thread - glad to see your shop is doing things.
I have a feeling a lot of our NP's and PA's will twindle down as we get another year of residents. They're already barely seeing patients now. Will probably keep them in triage for screening and fast track for low acuity stuff, but they get little business in the main ER now (except on lecture days and the night before lectures).
I hate these *****s in triage. I guess if they are there keeping a chair from floating away into space they have value, but don't let them order any work-ups that I have to correct later.
So much this.
They also don't know the word "injury".
"LEFT ARM PAIN" becomes a level-2 triage when its really an old woman who can't bring the wine glass to her lips anymore without a twinge in her arm.
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We're FFS/RVU based. No way can we put a doc in triage. The health system likes them screening patient's because it reduces the LWBS rate (they are now AMA's once screened).
I understand your frustration with correcting workups. I've seen my fair share of headaches that had unnecessary CT's (I tell a patient no need for a CT and they say "I just got one!"). CTA chest instead of a D-dimer, etc. Of course, it's hard for a PA/NP to figure out what each doc wants. Like anything, we have some who CT everything almost.
The best screen that I had was an elderly guy on Coumadin who fell, hit his head, had +LOC, and complained of hip pain. His family didn't want to call 911 and put him in a minivan instead. They managed to get him into a wheelchair when they got to the ER. This NP ordered a CBC and BMP (!!!!!!). No INR, no head CT, no hip x-ray. He ended up with a small subdural, a subcapital hip fracture, and an INR of 5. She didn't order anything that was really needed. Thankfully she's no longer with us.
I understand your frustration with correcting workups. I've seen my fair share of headaches that had unnecessary CT's (I tell a patient no need for a CT and they say "I just got one!"). CTA chest instead of a D-dimer, etc. Of course, it's hard for a PA/NP to figure out what each doc wants. Like anything, we have some who CT everything almost.
The best screen that I had was an elderly guy on Coumadin who fell, hit his head, had +LOC, and complained of hip pain. His family didn't want to call 911 and put him in a minivan instead. They managed to get him into a wheelchair when they got to the ER. This NP ordered a CBC and BMP (!!!!!!). No INR, no head CT, no hip x-ray. He ended up with a small subdural, a subcapital hip fracture, and an INR of 5. She didn't order anything that was really needed. Thankfully she's no longer with us.
How is this not malpractice? Is the health system not responsible for this?
How, at the least, is this not a case review with the administration on the hook?
HH
Because they have the heart of a nurse, and the medical knowledge of a potato.
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Because you're liable as their "supervisor"
It’s malpractice on the supervising doc yeah CMG dictate how we practice get all money and no liability
And presumably everything was done once the pt made it back to a room. This sounds like a sucky midlevel not doing their job in triage.
Hypothetically, would a full-time IM/FM doc who has experience in UC be beneficial to an ED's triage? Would cost the ED more than a midlevel, but less than an ED physician. But in the long run might make the experience better overall for EM physicians and patients. In the ED I've scribed in, triage was always run by 1 PA (Who had to have 5 years of ED experience) and 1 physician. But, the physician was an ED doctor and part of their contract was they had to do like 1-2 12 hour shift in triage a month or something like that. But it just seems silly to staff a physician on EM salary in a lower acuity area of the ED like triage. Most of the time it was ppl with minor I&D needs and antibiotics anyways.
Probably wouldn't be helpful as it's a different mindset. When I triage people (yes I sit in triage) I'm looking for emergencies. I turf all the sore throats, ankle pains, etc to my midlevels. I keep any patient who might be sick. Although a UC doctor might be a step up, they still aren't going to have the same radar attuned for emergencies.
Oh, I get it.
What I don't get is why we continue to accept this. We blame "CMG bad guys", but don't acknowledge that many of "us" do the same thing.
"Line docs" working in SDGs and for academic spots are often working under EM-trained directors and these directors establish the same type system. The directors don't sign the midlevel charts...they just pass all responsibility on the "line docs".
I fully understand why EM docs who work for CMGs are stuck. It's the MBA or RN suits in the C-suite making the call and CMG line docs have very little power.
However, there are plenty of us who don't work for CMGs, but under EM-trained medical directors who continue to toss their colleagues under the malpractice bus.
We should let these directors hear about it!
I know there are some directors like this on these forums. I wonder if they would like to comment.
HH
We shouldn't accept it. I work closely with my midlevels and don't let them indepedently dispo anyone. Even a tooth pain, I let them give me the 10 second spiel, then I go over the nursing triage note, and any vitals before agreeing to let them discharge.
For abdominal pains, I go over all the labs, imaging, and history. Sometimes I catch things they've missed or ask them to do additional testing.
We should not be signing charts on patients seen by a midlevel whom we know nothing about.
As veers said, I don't know why this should happen. If you have to sign a midlevel chart, they should at least present the patient to you.
Fully agree. The only way to have this happen is to have the CMG take responsibility for their staffing decisions, which is tricky to *make happen* locally when all your recommendations need to be escalated thru regional funnels to a central point such as Nashville, etc - where some overweight vasculopath will say "no" before consuming his next shrimp cocktail.
I'd say more, but I fear the wrath of the SDN ThoughtPolice.
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It's my license, but it's "their feels" over my job. Piss off a couple of them because they aren't getting to try their hand at cool cases or procedures and they'll start bitching about you. They make great money for CMGs. If they are an NP, then they also have some pull with the nurse mafia. You'll be out of that ER before you know it. I have crossed nurses before, been in the right, and also been out of that ER. Those nurses are still there. They're still faking charts and vitals, performing sloppy work, etc. I have seen plenty of other docs meet the same fate.
I have a mortgage to make.
The last two days I've had teenage males with UTI's come back to my main zone with scrotal ultrasounds ordered for their dysuria. Not only is that pointless, it delays me instantly discharging these kids when the come back since they go to ultrasound first.
I'd say something, but I know my karma and it'll be the real torsion that gets ignored and stays in the lobby for 6 hours
I'd say something, but I know my karma and it'll be the real torsion that gets ignored and stays in the lobby for 6 hours
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Yep.
This is why putting "Midlevels" or "Nurses" in triage to order things is not a game that anyone should want to play, whenever you have to be the other player on the other (receiving) end of the game.
I used to spend so much time at my last job trolling the waiting room deleting and adding orders to the garbage the midlevels would put in
My organization says that my wanker is as big as an aircraft carrier.
Doesn't make it true.
I'm betting it's close to the Penny
Yep. That aircraft carrier is close to the penny. Lol.
You guys beat me at my own game. Good on yah'll.
D
deleted109597
Mississippi State Medical Association with shots fired.
Nurses of course fire back.
Nurses of course fire back.
OMG
"#3- There are 22 states in the US that DO have full-practice authority. There is NO evidence that the care given by NPs is inferior to that of a physician. "
OMG
disgusting
"#3- There are 22 states in the US that DO have full-practice authority. There is NO evidence that the care given by NPs is inferior to that of a physician. "
OMG
disgusting
The other 13% are NPs and CRNAs.
Mississippi State Medical Association with shots fired.
Nurses of course fire back.
OMG guys.
You have to read the comments on that posting above by Ninja. The one by Amber Thomas. The comments are ridiculously outlandish. Some samples:
"Tonia Coker NP spend more time with the patient asking questions, actually doing quality assessments and teaching the patients....why?? Because they are nurses who know the value of quality patient care, patient education, love and kindness....that is why we are nurses..to care for others. Physicians do NOT oversee the NP that info is WRONG. I would encourage you to educate yourselves on the scope of practices that all nurses have to comply with."
"Kathy Windham My NP has saved my life by diagnosing and treating an illness which had been overlooked my my doctor. She also did the same thing for my mother who had been to several doctors and had even been hospitalized. My NP is my PCP now and will continue to be."
"Phara Paulemon Jimmy Dodson ...in almost 1/4 of states NPs own their practice sans MD oversight. This is what we’re fighting for in every state. As for asking questions MDs call each other all the time for advice. I’ve been a nurse for 17 years, have saved the ass of many doctors, and new residents with the “MD” title came to me for advice."
"Meagan Pinegar I trust nurse practitioners more than doctors. Every NP I have seen uses their knowledge to help diagnose issues, spends time getting to know me, and resolves any illness I may have. My doctors I have used would bring in a laptop, place my symptoms in a web search, and start deduction to see what I could have."
"Amber Wilson Lovitt Ada Nancy Anoro I was a RN for a decade prior to becoming an NP. I'll go toe to toe with a resident any day."
"Shayla Shamir Ada Nancy Anoro I applaud you, as a woman of color, for pursuing a medical degree. To be quite fair, there is a difference in a NP and MD/DO's education, but the fact remains that nurses with experience know more than a new resident on any floor. "
"Diedre Harmon I have received better care from a Nurse Practitioner than I have from most doctors. In fact, it was a Nurse Practitioner who found a brain aneurysm in December 2018 that I had been reporting blurred vision to different doctors for four years!"
"Reid Kelly Tori Lord Carr So receiving a masters degree online is not adequate for nurses? Spending 4 years in undergraduate school doing clinical hours + X amount of years working (Usually in ICU or emergency departments) and then getting a degree online isn’t appropriate? My two year NP program probably isn’t as “in depth” as a PA program, but that’s because my experience as an ICU nurse and a two year online program is MORE than adequate to be an independent provider."
Perhaps the best one...
"Jennifer Dodd Taylor Beverly Byars Padgett I have been to school more years than my collaborating physician and I promise you med school is easier than my doctoral program!" (she is, according to her Facebook profile, a Family Nurse Practicioner at an Urgent Care)
And there are more!!!!
My jaw dropped reading these
You have to read the comments on that posting above by Ninja. The one by Amber Thomas. The comments are ridiculously outlandish. Some samples:
"Tonia Coker NP spend more time with the patient asking questions, actually doing quality assessments and teaching the patients....why?? Because they are nurses who know the value of quality patient care, patient education, love and kindness....that is why we are nurses..to care for others. Physicians do NOT oversee the NP that info is WRONG. I would encourage you to educate yourselves on the scope of practices that all nurses have to comply with."
"Kathy Windham My NP has saved my life by diagnosing and treating an illness which had been overlooked my my doctor. She also did the same thing for my mother who had been to several doctors and had even been hospitalized. My NP is my PCP now and will continue to be."
"Phara Paulemon Jimmy Dodson ...in almost 1/4 of states NPs own their practice sans MD oversight. This is what we’re fighting for in every state. As for asking questions MDs call each other all the time for advice. I’ve been a nurse for 17 years, have saved the ass of many doctors, and new residents with the “MD” title came to me for advice."
"Meagan Pinegar I trust nurse practitioners more than doctors. Every NP I have seen uses their knowledge to help diagnose issues, spends time getting to know me, and resolves any illness I may have. My doctors I have used would bring in a laptop, place my symptoms in a web search, and start deduction to see what I could have."
"Amber Wilson Lovitt Ada Nancy Anoro I was a RN for a decade prior to becoming an NP. I'll go toe to toe with a resident any day."
"Shayla Shamir Ada Nancy Anoro I applaud you, as a woman of color, for pursuing a medical degree. To be quite fair, there is a difference in a NP and MD/DO's education, but the fact remains that nurses with experience know more than a new resident on any floor. "
"Diedre Harmon I have received better care from a Nurse Practitioner than I have from most doctors. In fact, it was a Nurse Practitioner who found a brain aneurysm in December 2018 that I had been reporting blurred vision to different doctors for four years!"
"Reid Kelly Tori Lord Carr So receiving a masters degree online is not adequate for nurses? Spending 4 years in undergraduate school doing clinical hours + X amount of years working (Usually in ICU or emergency departments) and then getting a degree online isn’t appropriate? My two year NP program probably isn’t as “in depth” as a PA program, but that’s because my experience as an ICU nurse and a two year online program is MORE than adequate to be an independent provider."
Perhaps the best one...
"Jennifer Dodd Taylor Beverly Byars Padgett I have been to school more years than my collaborating physician and I promise you med school is easier than my doctoral program!" (she is, according to her Facebook profile, a Family Nurse Practicioner at an Urgent Care)
And there are more!!!!
My jaw dropped reading these
Lol...
I wish I could post anonymously. I'd love to delicately fan the flames.
"I was an RN for a decade prior to taking some online classes and becoming an NP."
"I'll go toe to toe with a resident anyday."
"I'll go toe to toe with a resident anyday."
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"I'm as good as an untrained doctor, so let me practice independently."
"I was an RN for a decade prior to taking some online classes and becoming an NP."
"I'll go toe to toe with a resident anyday."
I'm sure she saved her life by diagnosing Postural Orthostatic Tachycardia Syndrome/Cardiac Dysautonomia... otherwise known as cardiac fibro.
This is exactly why a jailer can become a great attorney by studying online, an electrician can study online to design a space shuttle as an aerospace engineer, a cashier can become a CPA online.
Seriously, if you want respect as an "independent practitioner," don't try to use the excuse that an online self-study program can ever remotely be equivalent to medical school and residency training. Medical schools arrange clinical rotations and ensure that faculty are properly qualified to supervise and teach. WCI's forum had someone posting about a nurse trying to arrange a pediatric rotation. This has been the experience of nurses in my ER. They have had to arrange their own clinical rotations. How is that proper oversight to ensure clinical preceptors actually teach if they teach one study here and there, get no constructive feedback, and no specific requirements of the rotation. This isn't even to say that there are no residency programs to provide post-graduate training.
I have a feeling that the goal of these NP programs is to flood the market and create power in numbers to petition states to allow autonomous practice.
Bingo. They've figured out (correctly so) that politicians are the only ones they need to persuade to enact sympathetic policy. They've bolstered their ranks, organized their political arms, financed their lobbyists....and gone for the jugular. It's all very impressive really...when compared to what physicians have been able to accomplish. We're like dazed, absent minded professors who just assume that everyone takes our worth and value for granted. I always tell people to just open their eyes and look around them. Hospitals are run by nurses. Hell, our hospital CEO is a nurse. Physicians are quickly becoming part of a moribund legacy of healthcare dinosaurs. We have numbered days ahead if our current landscape is any indication of what the future portends. Hopefully I'm wrong.
15 more years and I'm out.
See, this nonsense is why I see a therapist (among other reasons).
We need to let them fail on their own account.
Just tonight, two "BEHOLD! GO TO THE ER!" Referrals:
One 51 year old female with "EKG referral". Told that she "could be having a heart attack".
Stone cold normal EKG. I mean... STONE. COLD. NORMAL. Discharged.
"I should sue them" - she said, as she walked out the door.
---
One 73 year old female [again!] for "IV antibiotics" for their chronic venous stasis for their fat, disgusting, inactive tib/fib regions that are so hardened with lipodermatosclerosis that there really is no helping it. The problem is this.... some Jenny McJennyson got ahold of them FIRST, and told them that this is "cellulitis" and must be "cured"; nevermind the fact that it has been there for years, as has their inability to walk from bedroom to kitchen without being winded.
Long talk. Like :90 seconds long. Discharged.
Nope.
Not doing it. Let them have their way. Create the divide. When they fail; the muggles will spurn them in favor of people with real medical knowledge.
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