How do we stop nurse practitioners?

[masaraksh]

Not even dead bodies will change the nursing lobby. No matter how high it stacks. It will still be spun as somehow the fault of the physicians. Probably, it will be that we didn't support them enough, you see, that is why the death toll accrued.

There has virtually never been a political body that didn't seek, above all other priorities, to maintain itself. Cognitive dissonance on the scale of professional lobbying organizations ensures that any result that suggests that the group and its constituents may actually be the source of the problem ensures that the problem is promptly reframed so that blame is deflected.

NPs aren't going away, and they aren't going to be "stopped," either. If you openly oppose them, you set yourself up as a scapegoat. There is a mythology that doctors are all avaricious, sinister, operating in cahoots to keep the practice of medicine inaccessible to goodhearted nurses and others who would make it more available to the people. Questions like "How do we stop nurse practitioners?" feed into that perception. If you are going to even pose it, you gotta build your deeper concern right into it. Like:

"How do we stop patients from being harmed by underprepared, undereducated, and inexperienced, if well-meaning, midlevel providers?"

Yeah, it is longer, and not as catchy, but a lot harder to twist into evidence that the docs are trying to undermine other professionals for their own financial gain or out of some kind of mean-spirited guild based protectionism.

I mean, public school teachers unions and lobbies are even more insane. There a literally teachers who are have sexually assaulted minors that are not fired yet because of teachers unions.

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[masaraksh]

a family member emailed me the other day about how she didn't understand why her "psychiatrist" wanted to change her medication. I looked the person up - it's an NP. my family member doesn't work in healthcare and had no idea that she was seeing someone who is not a doctor because this NP markets herself as a psychiatrist to patients who don't know any better

Not like it matters, what pscych meds can NPs realistically prescribe? SSRIs? That **** is given out like candy anyway

 

[DNM]

The thread was asking for solutions to expanding NPs. There have been very few actual suggestions. Is there anything we can do politically about this?

 

[TaroBubbleTea]

The thread was asking for solutions to expanding NPs. There have been very few actual suggestions. Is there anything we can do politically about this?

We have to frame the problem as a patient safety problem, but I wouldn't know how to go about doing that.

 

[libraryismyhome]

We have to frame the problem as a patient safety problem, but I wouldn't know how to go about doing that.

My school has a scholarly concentration focused on patient safety. I aim to complete it and later use its knowledge to fight the NPs.
http://www.ihi.org/topics/patientsafety/pages/default.aspx


When a nurse is your health-care provider, you’re at risk
http://nypost.com/2015/01/06/when-a-nurse-is-your-health-care-provider-youre-at-risk/

 

[Psai]

"Would you like a nurse with a few months of writing classes or a real doctor in charge of your care?"

I'm not sure why this is difficult.

 

[gmbz]

When is this VA bill being voted on anyway? I am at least glad that it was delayed..

 

[Lucrezia]

"Would you like a nurse with a few months of writing classes or a real doctor in charge of your care?"

I'm not sure why this is difficult.

The way you talk about nurses on this board makes you appear incredibly insecure. You might want to work on that, lest you embarrass yourself on the wards in front of the 'real' doctors.

Just generally I have never understood why doctors / medical students get their knickers in a twist over NP scope of practice (okay, I do, it's 50% $$$, 50% turf war / ego). Let's be real - the majority of nurse practitioners just want to do the boring, basic, check-list stuff that you really don't need a medical degree to do properly anyway. If you want to fight with them over your right to see cookie cutter cases and perform the most mind-numbingly boring procedural work then be my guest. I'd rather let them have that stuff and leave the "real doctors" the more interesting work. It's also better for the health dollar - NPs charge less for the same thing. I wish they had taken off here in Australia tbh.

 

[OnePunchBiopsy]

My suggestion would be to utilize more PAs. They are trained using allopathic medical principles, and if well-trained & mentored could be a great replacement.

NPs require roughly 20 months of physician oversight before they can practice independently. If I were a primary care doc I would just hire a PA and not take on any NPs. No oversight, no independent practice.

 

[Psai]

The way you talk about nurses on this board makes you appear incredibly insecure. You might want to work on that, lest you embarrass yourself on the wards in front of the 'real' doctors.

Just generally I have never understood why doctors / medical students get their knickers in a twist over NP scope of practice (okay, I do, it's 50% $$$, 50% turf war / ego). Let's be real - the majority of nurse practitioners just want to do the boring, basic, check-list stuff that you really don't need a medical degree to do properly anyway. If you want to fight with them over your right to see cookie cutter cases and perform the most mind-numbingly boring procedural work then be my guest. I'd rather let them have that stuff and leave the "real doctors" the more interesting work. It's also better for the health dollar - NPs charge less for the same thing. I wish they had taken off here in Australia tbh.

Doing just fine on the wards and I am yale locks level secure. Thanks for the fascinating advice as it's clear that you know what you're talking about

 

[Launcelot]

There's no stopping a quickly growing group with enough money to bribe politicians and produce policy changes. Just go into a field where they don't affect you. Or pick up a JD and have fun in the medmal ring.

That last part kills me for some reason, haha!

 

[Lucrezia]

.

 

[Lucrezia]

My suggestion would be to utilize more PAs. They are trained using allopathic medical principles, and if well-trained & mentored could be a great replacement.

NPs require roughly 20 months of physician oversight before they can practice independently. If I were a primary care doc I would just hire a PA and not take on any NPs. No oversight, no independent practice.

Ahh that's interesting. Being in Australia I am not really familiar with PAs but they do sound like a viable alternative. I would be interested to see if there are any studies on the performance of PAs vs NPs. In any event we don't have either (in any significant capacity) in my country, but we need to reduce (well, more like stem) the cost of healthcare here too so I think it's something we should be looking seriously at.

 

[Psai]

Ahh that's interesting. Being in Australia I am not really familiar with PAs but they do sound like a viable alternative. I would be interested to see if there are any studies on the performance of PAs vs NPs. In any event we don't have either (in any significant capacity) in my country, but we need to reduce (well, more like stem) the cost of healthcare here too so I think it's something we should be looking seriously at.

If you're looking to reduce the cost of healthcare, there are many better ways of going about it than hiring undertrained pseudophysicians and pretending that the difference in salary will make a big dent in expenses

 

[libraryismyhome]

My suggestion would be to utilize more PAs. They are trained using allopathic medical principles, and if well-trained & mentored could be a great replacement.

NPs require roughly 20 months of physician oversight before they can practice independently. If I were a primary care doc I would just hire a PA and not take on any NPs. No oversight, no independent practice.

So finally there is one practical solution that we all can easily do in the future.
To make this boycotting possible, we would have to inform every primary care physician that NPs are trying to be same as them and replace them.

We also have to stop physicians from training NPs in schools. They could train PAs instead.

 

[medic86]

Hilarious GomerBlog post went something like, "Obama Appoints NP Surgeon General of the United States"

In all honestly the surgeon general should probably be a dietitian or gym teacher, because America needs to hustle.

Well, the Surgeon General of the Army is a nurse.

and not even an NP.

 

[BidingMyTime]

Not like it matters, what pscych meds can NPs realistically prescribe? SSRIs? That **** is given out like candy anyway

But this is the problem, NP's in many states CAN prescribe any psych med, for any reason. It doesn't have to make any sense. For example, a NP in my area routinely prescribes Zyprexa as a first line agent for insomnia. And she's a FP NP, not a "nurse psychiatrist." Why do you think there is any limit in the drugs an NP will prescribe, or that they won't prescribe drugs even if they have no idea what they are doing? The newer NP's are especially scary, even the staff RN's (who have much more practical experience) are flabbergasted at some of the stuff they come up with at my hospital. And I'm in state that requires physician oversight (which from what I've seen is usually so minimal, it might as well be non-existant.)

 

[W19]

But this is the problem, NP's in many states CAN prescribe any psych med, for any reason. It doesn't have to make any sense. For example, a NP in my area routinely prescribes Zyprexa as a first line agent for insomnia. And she's a FP NP, not a "nurse psychiatrist." Why do you think there is any limit in the drugs an NP will prescribe, or that they won't prescribe drugs even if they have no idea what they are doing? The newer NP's are especially scary, even the staff RN's (who have much more practical experience) are flabbergasted at some of the stuff they come up with at my hospital. And I'm in state that requires physician oversight (which from what I've seen is usually so minimal, it might as well be non-existant.)

They can't prescribe narcotics in some state, and some of them are trying to circumvent these restrictions... In any case, that is some scary stuff!

 

[Taurus]

You should assume that nursing midlevels (NPs, CRNAs, midwives) will have full independence in all 50 states within 10-20 years. Assume they will infiltrate the low hanging fruit in primary care, anesthesiology, ED, and derm. Assume that if your society tries to block them from certification they will create their own residencies and societies to become "board certified".

Then you should choose your specialty and type of practice based on those assumptions. Remember the laws of supply and demand. If a field gets saturated by providers, then income levels and job opportunities/security drop.

 

[masaraksh]

You should assume that nursing midlevels (NPs, CRNAs, midwives) will have full independence in all 50 states within 10-20 years. Assume they will infiltrate the low hanging fruit in primary care, anesthesiology, ED, and derm. Assume that if your society tries to block them from certification they will create their own residencies and societies to become "board certified".

Then you should choose your specialty and type of practice based on those assumptions. Remember the laws of supply and demand. If a field gets saturated by providers, then income levels and job opportunities/security drop.

Well Ortho, Surg, Heme/Onc, and Rads (although with probably lower reimbursement than in the golden years) should be aight for my lifetime.

 

[giantswing]

Saw a nursing student that had a shirt that said " be nice to your nurses, they keep your doctor from killing you accidentally."

I literally nearly sh** myself.

Know how many people would be dead if i did what all the flooor nurses called me and asked me to do?

So insulting. They actually believe this, too.

And its the pharmacists that keep me from killing patients.

 

[psiyung]

i had food poisoning a few nights back...went to local ED and the "doctor in charge" was a NP..wtf is going on with medicine?

 

[chipwhitley]

i had food poisoning a few nights back...went to local ED and the "doctor in charge" was a NP..wtf is going on with medicine?

The rug is being pulled out from under us while we're all delusional thinking we're still in charge. That's what's going on.

 

[W19]

The physicians before us have left us with that hot potato in our hands...

 

[username456789]

The physicians before us have left us with that hot potato in our hands...

And you keep idiotically suggesting that we intentionally make it worse.

I still haven't figured out whether you're a troll or just have no working knowledge of most things.

 

[W19]

And you keep idiotically suggesting that we intentionally make it worse.

I still haven't figured out whether you're a troll or just have no working knowledge of most things.

I probably have working knowledge in most things than you young man...

 

[aim-agm]

And you keep idiotically suggesting that we intentionally make it worse.

I still haven't figured out whether you're a troll or just have no working knowledge of most things.

I probably have working knowledge in most things than you young man...

The world is a vast, complex place. No one has working knowledge of most things, so it's best to try and be respectful and productive.

 

[managedcarefin]

You don't because you don't have power. NP's are cash cows to administrators and thats really all that matters, similar to how Spine is currently a cash cow. The difference with NP's is that that gravy train might never stop...

 

[Carbocation1]

What non-surgical specialties are safe from the Noctors? For those of us who are flexible in our interests, is it recommended to just suck it up and go into surgery for optimal job security, pay, and respect?

 

[libraryismyhome]

Noctor... This is brilliant. I will use this term from now.

 

[cbrons]

What non-surgical specialties are safe from the Noctors? For those of us who are flexible in our interests, is it recommended to just suck it up and go into surgery for optimal job security, pay, and respect?

Despite what the delusional surgeons on this website think, surgery is not "safe" from NPs either. There are 1st assists RNs right now who think they could do most of the procedures solo. There are NPs in every single surgical specialty right now mostly doing scut work but that will change.

 

[gmbz]

Someone mentioned a while back that Medicare will not be paying for NP first assists, only PA first assists?

If this is true, it would be a step in the right direction.

Despite what the delusional surgeons on this website think, surgery is not "safe" from NPs either. There are 1st assists RNs right now who think they could do most of the procedures solo. There are NPs in every single surgical specialty right now mostly doing scut work but that will change.

 

[cbrons]

Someone mentioned a while back that Medicare will not be paying for NP first assists, only PA first assists?

If this is true, it would be a step in the right direction.

It is RNs that won't be billed as first assistants, not NPs.

 

[W19]

You get attacked here when you say medical education needs a complete overhaul...

You have docs in the FM and psych forums saying that their job description is indistinguishable with NP they work with... and there is no triage when it come to allocating patients to NP/PA/MD/DO... Why should these physicians get paid more? If this is not a wake up call, I don't know what is?

 

[Carbocation1]

 

[W19]

We can not effectively train PCP in 8 years (3+3+2)...

 

[Carbocation1]

"distance-based online learning" in ortho... only a matter of time before they pick up the scalpel

 

[Yadster101]

But dont we need to control their number and contain them within uninhabitable third world states? How can we put them on a tight leash like we do to PAs?

Idk if PAs are on a tight leash...From my understanding the # of NPs that practice independently is similar to the # of PAs that own their own practice nationally. Also the NPs seem to agree that they are equivalent to PAs, so if they gain more rights then I'm sure the PAs would also gain more rights.

Edit: PAs can hire a doctor to "supervise" them and while the PA owns the practice.

 

[Yadster101]

The problem is when midlevels want to become terminal providers who work independently (i.e. not "mid" anything)

I'm all for work-life balance. Most people going down the PA/NP care more about lifestyle than advancing their knowledge or becoming excellent providers. Unfortunately, many doctors and doctors in training today have drifted towards that mentality as well. This is how we help close the gap between the value we provide and that of midlevels.

Since you're in the real world, whats the actual relationship between residents/attendings and mid-levels? From my limited experience it seems like everyone is cool with e/o. Is that all just fake? Is there a great deal of animosity within medical teams that include mid-levels?

 

[gmbz]

As a nurse going into medicine I work closely with a group of Cardiologist's with a few NP/PA's in the group as well.

I have asked almost all of the MD's I work with how they feel about mid-level encroachment and the response is almost unanimous. Keeping in mind we only represent one practice in the Midwest..

The physicians state that the mid-level usage is for the patients that already have a plan set in place by one of our MD's. Example, Heart failure patient has an acute on chronic exacerbation and is admitted to the hospital. The physician sets up a plan and medication regime. The patient will follow up with the mid-level over the course of the next month or two due to the physician's schedule being booked up. If our mid-levels get over their head perse, they consult the physician.

Thoughts on this model guys?

 

[username456789]

I probably have working knowledge in most things than you young man...

Not grammar.

 

[W19]

Not grammar.

Grammar is definitely not one of them...

 

[Cinclus]

As a nurse going into medicine I work closely with a group of Cardiologist's with a few NP/PA's in the group as well.

I have asked almost all of the MD's I work with how they feel about mid-level encroachment and the response is almost unanimous. Keeping in mind we only represent one practice in the Midwest..

The physicians state that the mid-level usage is for the patients that already have a plan set in place by one of our MD's. Example, Heart failure patient has an acute on chronic exacerbation and is admitted to the hospital. The physician sets up a plan and medication regime. The patient will follow up with the mid-level over the course of the next month or two due to the physician's schedule being booked up. If our mid-levels get over their head perse, they consult the physician.

Thoughts on this model guys?

To me, this sounds like how things should be done and how midlevels were originally intended to be utilized. I think they can absolutely be helpful and have their place in healthcare provision, but it cannot be taken too far.

 

[ACSurgeon]

Since you're in the real world, whats the actual relationship between residents/attendings and mid-levels? From my limited experience it seems like everyone is cool with e/o. Is that all just fake? Is there a great deal of animosity within medical teams that include mid-levels?

Mid-levels on surgery teams are incredibly helpful. They are only interested in working their 3-3.5 days per week with no call or weekend responsibility. They seem to have NO interest in taking on more responsibility. They defer to the senior resident or attending with all significant management decisions. They execute plans and write notes. They address some nursing calls but once any patient acts sick, they bump it up.

Maybe my experience is unique. Maybe surgery is unique. I have yet to meet a mid-level who thinks they are anywhere near close to being autonomous or close to physicians in knowledge or skills.

 

[qwerty89]

You should assume that nursing midlevels (NPs, CRNAs, midwives) will have full independence in all 50 states within 10-20 years. Assume they will infiltrate the low hanging fruit in primary care, anesthesiology, ED, and derm. Assume that if your society tries to block them from certification they will create their own residencies and societies to become "board certified".

Then you should choose your specialty and type of practice based on those assumptions. Remember the laws of supply and demand. If a field gets saturated by providers, then income levels and job opportunities/security drop.

I don't understand why more people don't come to the same conclusion. There will be no reversal of these laws in any state. Even if outcome studies showed NPs were providing inferior care by that point the horse it already out of the barn. They may have their own "flexner report" regarding nursing education and make it more rigorous, but independent NPs will remain.

The fields that have erred on the side of undersupply such as Derm currently enjoy the best of both worlds. They can utilize NPs and bill for their services in their clinics allowing them to maximize their revenue and $$$/lifestyle ratio. However, whenever there is a shortage people will try to find alternatives eventually, which in this case means more independent NPs and maybe even PAs in the future. Anesthesia formerly, and even currently in some areas, loved having CRNAs to stool-sit so they could manage more ORs at once and therefore increase their $$$. Worked well for a while and despite the doom and gloom in the mid 90s anesthesia did well. However, eventually those same stool sitters are going to wonder why they can't work independently and fight for their right to do so.

On the other hand some fields like Cardiology and Radiology have erred on the side of oversupply. This cuses pain in the short term as the job market is worse and offers are for lower $$$ with less vacation, etc. But this prevents NPs/PAs from encroaching on their turf to a certain extent.

The other issue is that once you have independent nursing providers you lose the mechanism by which to control the total number of providers. THIS is the big one because more providers = ****tier job offers. Nowadays you have CRNA diploma mills which are a cash cow for the schools. And there is nothing the American Society of Anesthesiologists can do about it.

 

[ACSurgeon]

As a nurse going into medicine I work closely with a group of Cardiologist's with a few NP/PA's in the group as well.

I have asked almost all of the MD's I work with how they feel about mid-level encroachment and the response is almost unanimous. Keeping in mind we only represent one practice in the Midwest..

The physicians state that the mid-level usage is for the patients that already have a plan set in place by one of our MD's. Example, Heart failure patient has an acute on chronic exacerbation and is admitted to the hospital. The physician sets up a plan and medication regime. The patient will follow up with the mid-level over the course of the next month or two due to the physician's schedule being booked up. If our mid-levels get over their head perse, they consult the physician.

Thoughts on this model guys?

The problem is when a midlevel thinks they understand how decisions are made and become arrogant enough to think they are capable of making the plan rather than implementing it. I have not seen this is surgery or critical care. Sounds like this is the problem facing EM and primary care.

You have enough NPs who have done their job for 5-10 years and then they become convinced that they can train the next generation of "specialized" NPs. That's how knowledge and skills get diluted and degraded from one generation of NPs to the next.

The above is mostly theoretical. Again, I have not met any NPs who are interested in having more responsibility. They seem content with their role for the most part.

 

[Yadster101]

Mid-levels on surgery teams are incredibly helpful. They are only interested in working their 3-3.5 days per week with no call or weekend responsibility. They seem to have NO interest in taking on more responsibility. They defer to the senior resident or attending with all significant management decisions. They execute plans and write notes. They address some nursing calls but once any patient acts sick, they bump it up.

Maybe my experience is unique. Maybe surgery is unique. I have yet to meet a mid-level who thinks they are anywhere near close to being autonomous or close to physicians in knowledge or skills.

I actually shadowed a group of 2 general surgeons and 2 mid-levels in a rural setting and one of the PAs use to take call before she had a baby. The PA said that if there was a call at like 2am she would come in and determine if surgery was needed or if the pt could just come in in the morning.

In the OR the PA was pretty much just retracting which looks ridiculously easy. Couldn't you just train a regular RN, getting paid less than a NP/PA, to execute orders, write notes, retract, etc.? Also do surgeons that supervise a PA get paid more for this?

 

[Carbocation1]

Guys we really need to step it up and take ownership of medicine and ALL specialties. The previous generation of greedy fat cats have really screwed us over by selling out to the people in suits who have no understanding of medicine.

Read this "entrepreneur's" future vision of turning medicine into fast-food healthcare. This will be the future unless we take action.

"By 2030, just 15 years from today, there will be ~70 million Americans over 65yo. Today, there are ~30 million. Coupled with a predicted physician shortage, I believe this calls for disruptive innovation from entrepreneurs. Given that the entire healthcare sector is performance based.. My business model seeks to have high accountability (outcomes in real time/costs in real time).

My employees which constitute my brand, my franchise, will be adeptly trained in one to three outpatient surgical procedures. The inspiration for this came from military medics, in which low income retail and part time restaurant workers enter 6-8 week boot camps and are capable of handling trauma scenarios on the battle field similar to what a trauma surgeon would encounter here. By employing these training tactics onto the general population, I will fuel job promotion.

By creating a new class of caretakers that have been extensively trained in just 1-3 surgeries, we will reduce the cost curve by being able to offer a menu of care, in a retail clinic franchise format. Keep in mind that the training protocols will always be aware of the limitations posed by such a model. And our employees will have to endure sustained and prolonged training to be considered ready to enter the workforce."

 

[Psai]

Guys we really need to step it up and take ownership of medicine and ALL specialties. The previous generation of greedy fat cats have really screwed us over by selling out to the people in suits who have no understanding of medicine.

Read this "entrepreneur's" future vision of turning medicine into fast-food healthcare. This will be the future unless we take action.

"By 2030, just 15 years from today, there will be ~70 million Americans over 65yo. Today, there are ~30 million. Coupled with a predicted physician shortage, I believe this calls for disruptive innovation from entrepreneurs. Given that the entire healthcare sector is performance based.. My business model seeks to have high accountability (outcomes in real time/costs in real time).

My employees which constitute my brand, my franchise, will be adeptly trained in one to three outpatient surgical procedures. The inspiration for this came from military medics, in which low income retail and part time restaurant workers enter 6-8 week boot camps and are capable of handling trauma scenarios on the battle field similar to what a trauma surgeon would encounter here. By employing these training tactics onto the general population, I will fuel job promotion.

By creating a new class of caretakers that have been extensively trained in just 1-3 surgeries, we will reduce the cost curve by being able to offer a menu of care, in a retail clinic franchise format. Keep in mind that the training protocols will always be aware of the limitations posed by such a model. And our employees will have to endure sustained and prolonged training to be considered ready to enter the workforce."

Wow. They just want to make a ton of money by exploiting their workers and turning them into widget producers. Unbelievable. What does he even think he's innovating

 

[Carbocation1]

Wow. They just want to make a ton of money by exploiting their workers and turning them into widget producers. Unbelievable. What does he even think he's innovating

21st century "innovation" merely consists of lazily throwing some buzzwords such as "disruptive innovation," "real-time outcomes," and "reducing the cost-curve." Meanwhile, physicians who are supremely trained to take care of individuals in their most vulnerable states have to worry about being squeezed out by mid-levels/fast-food health care workers.