We Choose NPs

[RustedFox]

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I'm going to pile-on:

My medical director has agreed to "train" two NP students who are presently RNs in our ER. One has been an RN for 5+ years, one for 15+ years.

He hates it.

He has said to me on a dozen-plus instances:

"Dude... they know NOTHING about reductive thinking or how to define their role in the ER."

"One of them zero-es in on ONE diagnosis, and tests for only that. Moving on, she tests for the NEXT diagnosis."

"The other will sit and listen for a half hour about how their sister's boyfriend was once a boy scout, and blah, blah, blah, blah, and what about the boy scout's FAMILY history?!"

He says that despite so, so many attempts at shepherding them thru "how to think", that they are both rated: "Just forget it!"

Knowing the two individuals involved, I'm not surprised.

I let him exhaust himself in front of me this weekend, then I said the magic words:

"I simply refuse to train MLP students."

He looked at me like I was a genius.

 

[NecFasc92]

Why physicians continue to train non-physicians is truly beyond me. Literally the only profession on earth that actively tries to lower their income and pass off their skills to other people. It is baffling and, honestly, offensive.

 

[Boatswain2PA]

I let him exhaust himself in front of me this weekend, then I said the magic words:

"I simply refuse to train MLP students."

He looked at me like I was a genius.

You shouldnt lump PAs in with that crap.

PA programs have 12-14 months of intense medical school-type didactic education, then 12-14 months of organized medical rotations. No, obviously not med school & residency, but a long way from the crap NP schools do.

 

[RustedFox]

You shouldnt lump PAs in with that crap.

PA programs have 12-14 months of intense medical school-type didactic education, then 12-14 months of organized medical rotations. No, obviously not med school & residency, but a long way from the crap NP schools do.

Do you want a response from me, or not? I give you the choice.

 

[southerndoc]

@RustedFox to continue with your IV antibiotic rant, there was a patient today that was referred from urgent care. Seen 2 days ago by a physician, had an "I&D" (small incision, "didn't get a lot out"). Went back for packing removal and was seen by an NP. Still having pain. Area slightly red. Referred to ER for IV antibiotics. The medical student who saw the patient initially knew he needed an I&D as the first was either inadequate by the urgent care physician or it was early then and has now accumulated pus. The resident and medical student did an I&D, got about 15-20 mL of frank pus, and off he went to continue his Bactrim. He asked why the NP couldn't have done that at urgent care. "Not sure, that's something you'll have to ask them. No need for IV antibiotics. All the IV antibiotics in the world wouldn't have helped until you had it drained. Should be good to go now."

 

[Splenda88]

Why physicians continue to train non-physicians/ medical students is truly beyond me. Literally the only profession on earth that actively tries to lower their income and pass off their skills to other people. It is baffling and, honestly, offensive.

Academia has bought into that interprofessional B$... Everyone brings valuable contribution to the "team" blah blah blah. But when something goes wrong, all the fingers are pointing in one direction...

 

[RustedFox]

@southerndoc

Dude. I have had dozens of small abscesses. I was a lifeguard. I have had dozens of abscesses in sensitive places Suntan oil. Sunscreen. They get into odd places. Small pop, and I'm good. Even my high-school girlfriend was "cool with it". Never needed abx beyond I&D. Take care of your junk, people.

 

[Boatswain2PA]

Do you want a response from me, or not? I give you the choice.

It's an internet discussion board, respond or not, up to you.

 

[Splenda88]

I don't think we should lump PA with NP...

 

[Apollyon]

@RustedFox to continue with your IV antibiotic rant, there was a patient today that was referred from urgent care. Seen 2 days ago by a physician, had an "I&D" (small incision, "didn't get a lot out"). Went back for packing removal and was seen by an NP. Still having pain. Area slightly red. Referred to ER for IV antibiotics. The medical student who saw the patient initially knew he needed an I&D as the first was either inadequate by the urgent care physician or it was early then and has now accumulated pus. The resident and medical student did an I&D, got about 15-20 mL of frank pus, and off he went to continue his Bactrim. He asked why the NP couldn't have done that at urgent care. "Not sure, that's something you'll have to ask them. No need for IV antibiotics. All the IV antibiotics in the world wouldn't have helped until you had it drained. Should be good to go now."

Dude - 20 mL of pus is a lot. Like, A LOT.

WTH?

 

[Boatswain2PA]

And probably shouldnt whine about how poorly trained your team is if you're not willing to help fix it by training them.

 

[GonnaBeADoc2222]

And probably shouldnt whine about how poorly trained your team is if you're not willing to help fix it by training them.

Not our jobs.

 

[RustedFox]

And probably shouldnt whine about how poorly trained your team is if you're not willing to help fix it by training them.

Not my "team", homeboy.
Furthermore, its exeplmary of the MLP proliferation.

I'm done.
Catch you later the same day. Or not

 

[RustedFox]

This mealy-mouthed nonsense.
I'm sick of it.
You do what I tell you to do.
You ask me to go see the patient, or you don't.
The vast majority of PAs put something stupid in the chart"
"A physician was available somet!!!me like ***ujw=333 for like, in the departmennnt.

Uh.

No.

 

[Boatswain2PA]

Not our jobs

I understand the feeling, but by not leading the team, the department, or the hospital, physicians have lost their position to direct the healthcare system.

So, maybe, since it's not your job to lead the team, it has become your job to do EXACTLY what that nurse/CEO tells you to do.

I'm sure they will expect the same obedience from you that some here expect from the MLPs.

 

[thegenius]

I'm going to pile-on:

My medical director has agreed to "train" two NP students who are presently RNs in our ER. One has been an RN for 5+ years, one for 15+ years.

He hates it.

He has said to me on a dozen-plus instances:

"Dude... they know NOTHING about reductive thinking or how to define their role in the ER."

How does one go about teaching someone to be a practitioner without formal education? The training must go on for years. Unless you are training them to do
- xrays for broken bones
- strep throat for sore throat
- write Rx for med refills (even that is scary)
- simple I&Ds on I&D on extremities. Abscess can’t be more than 2 cm long
- dental pain
- simple lacerations in extremities and forehead
- Simple UTI
- vaginal complaints

Basically every single thoracoabdominal complaint is a no go for these people
If the complaint actually involves an organ, then that’s a problem
No neuro
No ophtho
No nephro
No cardiology (EKGs are hard man!!)
No this and that

It’s a joke

 

[thegenius]

And probably shouldnt whine about how poorly trained your team is if you're not willing to help fix it by training them.

I dunno what kind of place others work at, but it is NOT our job to train RNs to become NPs. One thing is answering questions, giving pointers, stuff like that. Training? No way!

 

[Old_Mil]

I've seen this on TV 3 or 4 times

Each time I'm like

View attachment 268222

What is going on here is a convergence of the desire of health care administrators to cut payroll costs and the desire of nurses to give themselves raises and replace physicians as independent practitioners of primary care (for now) medicine.

 

[Groove]

You guys are so entertaining.

@RustedFox I could have done without the mental image of the speedo lifeguard sun tan oiled abscesses though.

 

[GonnaBeADoc2222]

I understand the feeling, but by not leading the team, the department, or the hospital, physicians have lost their position to direct the healthcare system.

So, maybe, since it's not your job to lead the team, it has become your job to do EXACTLY what that nurse/CEO tells you to do.

I'm sure they will expect the same obedience from you that some here expect from the MLPs.

You are incorrect, sir.

I'm more than happy to lead. Lead means you tell me about a case, I tell you what to do, nicely and professionally of course, with some educational pearls along the way, and you do it. I'm more than happy to explain my rationale, and educate. In fact, I really enjoy it. I worked with a PA about 30 years my senior the other day, and this is how it worked, and it was very nice for both of us.

Lead does not mean:
-You continue to order things like plain films for back pain, IV abx for simple cellulitis, labs for vomiting children, despite me repeatedly teaching you not to
-You blatantly ignore the triage protocol I wrote for you and continue to order whatever the F you want
-I give you explicit instructions to consult this or that, don't consult, discharge, admit, and you do the EXACT opposite.

 

[Shabeer]

Please, someone help me. I can't stop clicking refresh hoping for another rustedfox rant. I need an intervention.

 

[GatorCHOMPions]

I'll add one of my personal stories from "provider" in triage recently:

50ish y/o with HIV presents with a couple days of acute leg pain. US ordered from triage to "rule out DVT". Patient is whisked away from the ED for the study and 2-3 hour delay to seeing me. Exam: huge bullae, hot leg with edema, febrile.

Diagnosis: necrotizing fasciitis. Fortunately the end outcome was fair.

Stories like these actually help me feel positive about job security. If/when the NP independent takeover is more widespread, there's no doubt going to be considerably more bad outcomes and malpractice exposed. Perhaps this is required before the pendulum swings back in our favor.

 

[NicMouse64]

Why physicians continue to train non-physicians/ medical students is truly beyond me. Literally the only profession on earth that actively tries to lower their income and pass off their skills to other people. It is baffling and, honestly, offensive.

Wait what? What's wrong with training/teaching medical students? Dont you want well trained physicians for you and your family when you can no longer practice? I'm confused.

 

[NecFasc92]

Wait what? What's wrong with training/teaching medical students? Dont you want well trained physicians for you and your family when you can no longer practice? I'm confused.

It was late. I messed up 🙂. Fixed

 

[GeneralVeers]

I enjoy leading them. Yesterday on 9 hours of my shift, I had 2 PAs working with me. We saw 47 patients (I saw 30 of them). I made the other two see my ankle sprains, do all my I&Ds, and Lac repairs. Their ability to simple procedures freed me up to go see 2-3 patients myself while they were doing the procedures. At the end of the day I'm still 100x more efficient at just about everything than they are, so I make them do the time-consuming scutwork or simple nonsense I don't want to waste time dealing with.

Each and every patient they saw, I reviewed the chart prior to them talking to me, and we completely reviewed the labs and studies prior to discharge. I had to go see one of their patients who was a narc-head refusing to leave. After my conversation she decided there were greener pastures elsewhere. I don't mess with their BS ordering of rapid strep, RSV and flu on all these febrile kids, but I do intervene with the non-traumatic back films, blood work on young people and inappropriate head CTs.

 

[RustedFox]

You guys are so entertaining.

@RustedFox I could have done without the mental image of the speedo lifeguard sun tan oiled abscesses though.

They weren't bad. And I never wore a speedo. Typical mesh-inner shorts. Dad was a dentist, so I had access to local antiseptics and an 18 gauge needle. Pop and done. That was life.

 

[cyanide12345678]

My first day as attending i learned very quickly to not trust a mlp 😛 now i chart stalk all their patients, go through their orders and ask them about their patients so they present the patients to me even though they are not required to.

 

[TooMuchResearch]

Good for you. It took me a couple of hospital peer reviews.

My first day as attending i learned very quickly to not trust a mlp [emoji14] now i chart stalk all their patients, go through their orders and ask them about their patients so they present the patients to me even though they are not required to.

 

[Boatswain2PA]

now i chart stalk all their patients, go through their orders and ask them about their patients so they present the patients to me even though they are not required to

I think that is a great way to describe how I am "supervised" at the PRN shop where I work with EPs. They are available when I have questions, we often bounce thoughts off each other, and the good ones provide oversight by watching over the charts and asking questions to make sure they are comfortable with what I'm doing.

 

[Fox800]

I'm very happy that I work at a place without MLPs.

 

[Arcan57]

They do this **** all the time.
I seriously had to go to charge RN twice last night to get Kylee to do her job instead of plunking her wide-ass in front of a PC and watching a video for her "FNP" classes.

I enjoy when they’re on shift taking an actual test online and are crowdsourcing the answers because actually looking them up on google or (heavens forbid) a textbook is too hard.

 

[RustedFox]

Please, someone help me. I can't stop clicking refresh hoping for another rustedfox rant. I need an intervention.

Thanks. I come up with some good stuff, sometimes.

I'm composing my "RustedFox Rants: My Jackpot Lawsuit!" right now.

 

[GonnaBeADoc2222]

Thanks. I come up with some good stuff, sometimes.

I'm composing my "RustedFox Rants: My Jackpot Lawsuit!" right now.

Been looking forward to this one for awhile!

 

[Fletcher]

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.

Very very very smart.
Patient dies and you are on the hook no matter what.
The bigger worry is in states with full practice auhtority... where they do an 18 hour online course, get 500 "clinical" hours (of shadowing) and begin practicing medicine on unsuspecting patients with no oversight- so dangerous.

 

[Fletcher]

Mississippi State Medical Association with shots fired.

Nurses of course fire back.

yes physicians are concerned! for the safety of patients- our only concern. And those statistics are correct. Most people thing NP's should have oversight, it is otherwise dangerous for patients... and please don't go quoting any parachute study trying to convince us otherise. A new study proves parachutes are useless

 

[thegenius]

The use of PAs and NPs should be different than what we do now. Currently I bet most places function where the PA/NP pick up patients after they are triaged by looking at the chief complaint, and before (or if ever) a doctor sees them. Then they are presented at the last minute to the doc.

It should be the other way around, or switched up. Doctors should screen patients for an EMC first. If there isn’t one or if the case is otherwise simple and low risk, the patient get shuttled to the PA/NP section of the ER. Or the chart is flagged in the EMR as “suitable for NP/PA”, that kind of thing.

Of course the doc could also want to see or hear about the patient after the workup if they want.

The advantage of this system is that the doc gets to see the patient up front which gives us a lot more info about the patient than hearing a report.

 

[qwerty89]

 

[Matthew9Thirtyfive]

So that first NP ranted for five paragraphs about how NPs get zero education in medicine and are undereducated and unprepared to practice. And then says she prefers NPs to physicians for primary care.

 

[KeikoTanaka]

So that first NP ranted for five paragraphs about how NPs get zero education in medicine and are undereducated and unprepared to practice. And then says she prefers NPs to physicians for primary care.

She wants someone who will be mentally and emotionally a cheerleader rather than someone who will catch that diagnosis. Perhaps this is a more Female sentiment? Females utilize healthcare at a far higher rate than Males and perhaps want someone to "Talk to them". Not trying to be sexist, but given that NPs are majority female, and if they feel that way, might be more of a female thing.

 

[GeneralVeers]

She wants someone who will be mentally and emotionally a cheerleader rather than someone who will catch that diagnosis. Perhaps this is a more Female sentiment? Females utilize healthcare at a far higher rate than Males and perhaps want someone to "Talk to them". Not trying to be sexist, but given that NPs are majority female, and if they feel that way, might be more of a female thing.

It would be worthwhile to have an NP just go "talk" to these people for 20 minutes while I make the actual decisions. I hate the pointless blather and emotional hand-holding that some patients seem to thrive on.

 

[Groove]

Does anyone else have ICUs staffed completely at night by ACNPs? Our pulmonary group staffs the ICU completely with NPs at night so they can sleep. They run multiple other ICUs in town and have established that policy as of a year or two ago. Although I don't approve of the policy, I will say that most of the ACNPs up there are actually very talented. Anyway, I got called up from the ER for a failed airway tonight and ended up having to cric this supermorbid obese guy in a rotoprone bed who they had been coding for 20 mins after respiratory lost his airway. Luckily, we don't get called up there too much but does anyone else have an ICU with a similar setup? I would think it would be a medicolegal nightmare if something happened at night and there was no ICU attending around...

 

[Apollyon]

A few (1 or 2) years ago, a friend's husband was admitted to the Buffalo General Medical Center (formerly BGH, but that name creep). He had CABG, but they couldn't extubate. In the ICU, it was only NPs, and this was during the day. I wasn't impressed, to be honest.

 

[deleted109597]

I would think it would be a medicolegal nightmare if something happened at night and there was no ICU attending around...

You're talking about 90% of the ICUs in the US right there.

 

[GeneralVeers]

You're talking about 90% of the ICUs in the US right there.

Frightening that at night my hospitals only have NPs who can't intubate, or central/arterial lines.

 

[cyanide12345678]

So that first NP ranted for five paragraphs about how NPs get zero education in medicine and are undereducated and unprepared to practice. And then says she prefers NPs to physicians for primary care.

Hand holding and compassion is pretty much what most of these hypochondriac patients need a lot of times. A fairly large share of patients i see in the department have some sort of anxiety/depression/other psychiatric issue. The perception remains that NPs have more time. Maybe they do?

 

[cyanide12345678]

Frightening that at night my hospitals only have NPs who can't intubate, or central/arterial lines.

Id rather them not be trained for airways and Central lines. We can't train them with skills that we possess and then expect the administration to not replace us with cheaper labor.

The medicine residents that my training hospital had in the icu over night didn't know how to do Central lines either. They would keep calling the ER and asking for ER residents to come up and do it.

 

[MechEDoc]

Does anyone else have ICUs staffed completely at night by ACNPs? Our pulmonary group staffs the ICU completely with NPs at night so they can sleep. They run multiple other ICUs in town and have established that policy as of a year or two ago. Although I don't approve of the policy, I will say that most of the ACNPs up there are actually very talented. Anyway, I got called up from the ER for a failed airway tonight and ended up having to cric this supermorbid obese guy in a rotoprone bed who they had been coding for 20 mins after respiratory lost his airway. Luckily, we don't get called up there too much but does anyone else have an ICU with a similar setup? I would think it would be a medicolegal nightmare if something happened at night and there was no ICU attending around...

Yep. I've worked in similar situations multiple times. I'm like WTF? You have an ICU but can't to intensive care stuff? I remember being called to the bedside for a chest tube a guy I admitted the day before for chest pain, turns about the cause of his pain was a slowly evolving esophageal rupture, now that his right hemithorax was full of gastric contents, the noctor realized they were in over their head. I have had to intubate and line so many people in the ICU it's not even funny. How did medicine get to this point? I'm guessing it's because hospitals aren't about health care that much, they are more just meat processing plants. Health care "providers" are line item costs. Cheaper substitutes definitely help the bottom line.

 

[RustedFox]

Yep. I've worked in similar situations multiple times. I'm like WTF? You have an ICU but can't to intensive care stuff? I remember being called to the bedside for a chest tube a guy I admitted the day before for chest pain, turns about the cause of his pain was a slowly evolving esophageal rupture, now that his right hemithorax was full of gastric contents, the noctor realized they were in over their head. I have had to intubate and line so many people in the ICU it's not even funny. How did medicine get to this point? I'm guessing it's because hospitals aren't about health care that much, they are more just meat processing plants. Health care "providers" are line item costs. Cheaper substitutes definitely help the bottom line.

Not my shop.
We are strictly forbidden from doing procedures outside of the ER except in a code situation. ICU doc comes in for situations such as this.

 

[TooMuchResearch]

Our community tertiary care center is staffed by CCM physicians at night. It's great.

Does anyone else have ICUs staffed completely at night by ACNPs? Our pulmonary group staffs the ICU completely with NPs at night so they can sleep. They run multiple other ICUs in town and have established that policy as of a year or two ago. Although I don't approve of the policy, I will say that most of the ACNPs up there are actually very talented. Anyway, I got called up from the ER for a failed airway tonight and ended up having to cric this supermorbid obese guy in a rotoprone bed who they had been coding for 20 mins after respiratory lost his airway. Luckily, we don't get called up there too much but does anyone else have an ICU with a similar setup? I would think it would be a medicolegal nightmare if something happened at night and there was no ICU attending around...

 

[Groove]

Yep. I've worked in similar situations multiple times. I'm like WTF? You have an ICU but can't to intensive care stuff? I remember being called to the bedside for a chest tube a guy I admitted the day before for chest pain, turns about the cause of his pain was a slowly evolving esophageal rupture, now that his right hemithorax was full of gastric contents, the noctor realized they were in over their head. I have had to intubate and line so many people in the ICU it's not even funny. How did medicine get to this point? I'm guessing it's because hospitals aren't about health care that much, they are more just meat processing plants. Health care "providers" are line item costs. Cheaper substitutes definitely help the bottom line.

Yeah, what I don't think the ICU docs realize is that they are providing evidence to the world that you really don't need an MD/DO in the ICU 24/7. Because the NP can do everything they can...right? That's the message they are sending. All to make their lives a little more easier so they don't have to take nights. We've just got to be careful not to do the same thing in the ER.