How do we stop nurse practitioners?

[Psai]

None of the new RN grads I know plan on just being an RN for the rest of their lives. They all want to be an NP, CRNA, etc.

This one girl I know was "accepted" into an NP program before she even took her RN boards. So after 1-2 years of taking fluff classes, she's gonna be handing out meds like candy in a white coat probably calling herself a doctor.

I have to give it to the nursing lobby. They have really out done themselves.

There are people who go into an accelerated combined programs with a masters making them an np

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[cbrons]

None of the new RN grads I know plan on just being an RN for the rest of their lives. They all want to be an NP, CRNA, etc.

This one girl I know was "accepted" into an NP program before she even took her RN boards. So after 1-2 years of taking fluff classes, she's gonna be handing out meds like candy in a white coat probably calling herself a doctor.

I have to give it to the nursing lobby. They have really out done themselves.

You forgot the part in the middle, where after the fluff classes, she gets preceptored by an M.D. who gets paid tons of $$ while the med students get ignored.

 

[Dranger]

K, bud-- There's a solid chance that I've been around medicine longer than you've been alive.

Let me guess, you're a nurse? Lol.

K, bruh. When are we going to progress from e-peen measuring to ad hominem smacks? Sounds like it could be some fun.

In all reality unless you produce some peer reviewed studies showing poorer outcomes associated with NP driven care or convince physicians to completely stop hiring NPs, you will never garner any support from the general public or legislators. Fact is, anything less is just whiny bitching behind closed doors.

 

[Señor S]

"Was told by a physician that pharmacists are not doctors." https://www.reddit.com/r/pharmacy/comments/2z3now/was_told_by_a_physician_that_pharmacists_are_not/

"First year residents get a bit of this out of their system early on. The rigors of residency beats it out of them. I've worked with several physicians who said they came around when a pharmacist "caught a mistake and saved my ass." So let them talk for now. They'll figure it out eventually that we are a team."

"I had a doctor go ape**** over me requesting chart notes to get a prior authorization. He threatened to get me fired and report me for trying to obtain confidential information. I tried to explain how the health plan needs chart notes otherwise the clinical staff won't approve paying for someone's Invega and he goes "do you even have an experience dealing with psychotics!?" I wanted to say "I do now""

What's wrong with those statements? Not to mention that most of the comments in the link you posted are very humble and even deferential (compare to physicians who can't go 20 minutes without asserting their superiority over other occupations/specialties/practitioners etc etc).

 

[W19]

2:40 minutes

 

[Hotei]

Yes, I am totally making it up on an anonymous forum for my own personal gain, oh wait.

I am not suggesting NPs> or equal to Physicians, but there are NP programs out there (ACNP/Acute not FNP) that teach all of these skills. I don't know if you are actually "pre-med" or a "med-student" but how about you get your feet wet before denouncing something you know nothing about.

As for NP education I feel it should be elevated to be more stringent, but the blanket notion that PAs are simply better than NPs across the board is simply laughable and frankly, uninformed. Too many NPs and PAs do jump right into school without experience, the hallmark advantage of "mid-levels" before was their seasoned medical experience.

K, bruh. When are we going to progress from e-peen measuring to ad hominem smacks? Sounds like it could be some fun.

In all reality unless you produce some peer reviewed studies showing poorer outcomes associated with NP driven care or convince physicians to completely stop hiring NPs, you will never garner any support from the general public or legislators. Fact is, anything less is just whiny bitching behind closed doors.

When you initiate this type of statement (quote 1), followed by attempting to take the moral high ground when someone responds (quote 2), it makes you look foolish.

 

[cbrons]

In all reality unless you produce some peer reviewed studies showing poorer outcomes associated with NP driven care

True, but can those studies actually be done? Ethically speaking. I mean on a large sample of patients with a variety of conditions, not type 2 diabetes protocolized treatment for insulin titration

 

[Psai]

Of course they can. You do it reteospectively with very large study populations. You'll have a lot of confounders but if you look at multiple sites in multiple geographic locations you might be able to statistically control for them.

Alternatively you could look specifically at places that switched from MD to NP care in ICUs and ERs, of which there are many.

Or, if you could get access to them, you could look at hospital complaints or patient safety reports and calculate rates between providers by number/severity of patients treated.

The CRNAs have already done these types of studies.

Have you read any of those studies?

 

[ACSurgeon]

True, but can those studies actually be done? Ethically speaking. I mean on a large sample of patients with a variety of conditions, not type 2 diabetes protocolized treatment for insulin titration

Of course they can. You do it reteospectively with very large study populations. You'll have a lot of confounders but if you look at multiple sites in multiple geographic locations you might be able to statistically control for them.

Alternatively you could look specifically at places that switched from MD to NP care in ICUs and ERs, of which there are many.

Or, if you could get access to them, you could look at hospital complaints or patient safety reports and calculate rates between providers by number/severity of patients treated.

The CRNAs have already done these types of studies.

Have you read any of those studies?

I haven't. But anyways it would be easier to show non-inferiority with a poorly designed study. Demonstrating superiority would require a much better study and would be harder

 

[Psai]

Not in depth, abstract only. Lots of criticism from physicians about how they were designed. But you know, one study is as good as the next when it comes to politics. We have totally missed the bus on that front.

It's true. The time points are short, the variables are useless, the data points are irrelevant and the conclusions are questionable but the only important part is that they choose things that enable them to say "there's no measurable difference" which they inflate to "just as good or better than" with a nonsense paper that wouldn't be picked up by anything other than a crappy, no-name nursing journal.

But why would you need a study for something obvious? I know that pilots are better than flight attendants at flying planes even without a double-blinded randomized control trial.

 

[Mjolner]

They didn't write it for you. Say what we will about nurses, they know their audience far better than we do.

No, they don't. However, the PR departments that their union hires do.

 

[yogurt0531]

I am a nurse who never wanted to become an NP because of bad personal experience. My school NP didn't diagnose my ear infection but common sense tells me that my ear should never hurt that bad... So I went to my primary care physician... I'm unsure if I want to do primary care in medicine in the future, but the quality of care by NPs concerns me so... I do respect nurses who practice good nursing very much.

 

[jw3600]

When you initiate this type of statement (quote 1), followed by attempting to take the moral high ground when someone responds (quote 2), it makes you look foolish.

You put that more eloquently than what I was attempting.

 

[eye love lamp]

PharmDs, NPs, DNPs, DNAPs, CRNAs, etc are all taking a dump on our profession every single day. They think they can do our job better than us. They are being trained to do every part of a physician's job until the physician is not needed anymore. Sad times.

I know a friend who sat down with his school's dean out of concern for the future of physicians. His response was that "physicians will always be the head of the healthcare team" and " an MD is the powerful degree in the world and opens so many doors." Bullcrap. Mind you this dean only work as a physician 3-4 weeks per year. He is profiting off students - basically smiling at us while putting his foot down on our throats.

lol what?

You disagree that the MD is the head of the Healthcare team? You disagree that getting an MD opens doors?

I think you're just rambling doom and gloom statements here.

 

[eye love lamp]

Are all these new "mid-levels" driving down physician salaries?

I was talking with someone the other day, and they were saying how hospitalists were only making 120k-130k in certain places.

That's very low for an MD/DO. But an NP/PA who make that would be more than happy.

Can you find one job posting for a full time hospitalist position that pays that salary? I've seen my colleagues' job hunt (in 2 different major cities and 1 suburban/semi rural) and all three started around $250k. That was for 40 hours/week.

 

[Psai]

2:40 minutes

Huh, that's the first time I've heard a lawyer introduce themselves as a doctor

 

[ACSurgeon]

Huh, that's the first time I've heard a lawyer introduce themselves as a doctor

Next they'll start wearing white coats.

 

[Psai]

Next they'll start wearing white coats.

Who doesn't? It's already spread to social workers, nursing students and nutritionists. I'm starting to recognize doctors by their lack of the white coat.

 

[ACSurgeon]

Who doesn't? It's already spread to social workers, nursing students and nutritionists. I'm starting to recognize doctors by their lack of the white coat.

Surgeons are recognized by their swagger. I haven't seen others try to take that away from us...

 

[Bearcat74]

I am an NP. I can tell you this, in this age of Obamacare, and rising medical expenses, hospitals and insurance companies are going to do whatever it takes, to save a buck. 21 states now allow autonomous practice by NPs. In 10 years, it will be 50 states. Do you really think that an insurance company will pay a FP MD $75 for an office visit for txmt of an ear ache, while they can pay the NP $40? Nope.... just follow the money..... That's the way it always has been, and that is the way it always will be. Primary care will be run by NPs, whether the AMA likes it or not.

 

[OnePunchBiopsy]

Surgeons are recognized by their swagger. I haven't seen others try to take that away from us...

I have heard that surgeons call it "walking."

 

[IlDestriero]

The CRNAs have already done these types of studies.

That's not really true.
Their big studies that they so frequently cite have some issues, not the least of which was the use of billing codes to compare those directed to not, ignoring the fact that many don't bill the correct code (right or wrong) as physician directed care even though they are directed, to avoid the risk of exposure to billing fraud if they miss an extubation, etc.
There are other issues, but that's a big one, outcomes improperly assigned to the wrong group.

 

[giantswing]

When i am an attending, i will refuse crnas wo an attending, not allow crna students on my cases, and will not hire nps.

 

[TBV]

When I'm an attending I will start each morning by sacrificing an NP to the blood god

 

[FiveOClock]

K, bruh. When are we going to progress from e-peen measuring to ad hominem smacks? Sounds like it could be some fun.

In all reality unless you produce some peer reviewed studies showing poorer outcomes associated with NP driven care or convince physicians to completely stop hiring NPs, you will never garner any support from the general public or legislators. Fact is, anything less is just whiny bitching behind closed doors.

As long as NPs are not allowed to practice independently, I don't care how many there are.

 

[Mjolner]

When I'm an attending I will start each morning by sacrificing an NP to the blood god

This is what the AMA should have been doing all along!

 

[W19]

Get real. No you won't. You won't even get that option.

There is a spine surgeon I worked with that did that. He did his case only with anesthesiologist (no CRNA) .. Everyone thought he was an a$$.

 

[CyberMaxx]

When i am an attending, i will refuse crnas wo an attending, not allow crna students on my cases, and will not hire nps.

Get real. No you won't. You won't even get that option.

I thought I remember a conversation in the surgery forum a while back where @Winged Scapula said that she did something similar to what giantswing is suggesting.

 

[IlDestriero]

When i am an attending, i will refuse crnas wo an attending, not allow crna students on my cases, and will not hire nps.

The first and third one you can do, find a place to operate that has MDs and hire your own PA(s). The second one will be a problem if your hospital anesthesia group trains CRNAs. That's not a request that will likely be honored and may not be easy to honor. Though it depends on your power within the hospital and if they have a lot of other options to staff rooms.
Chief of surgery and hospital board member, "absolutely sir!", vs newer general surgeon who seems to specialize in fecal disimpactions and 1am gall bladders, "sorry but no."

 

[LoudBark]

As long as NPs are not allowed to practice independently, I don't care how many there are.

Be careful what you wish for.

A best case scenario is that all 5o states, Wash DC, and all US Territories allow them to work independently.

Why? If they work independently there is no supervision by physicians and they are on their own and completely responsible for all decisions and actions they make, good and bad.

If they are required to always work under a physician, you (yes, you) can and will be responsible for poor decisions they make if you are supervising them. If you try to counter this and say you won't ever supervise them, you are limited in what and where you will practice. Only a couple of specialties don't use them in any capacity (pathology? diagnostic radiology?, although interventional radiology does use them). If you work completely independently and open shop in private practice, sure you don't have to hire them, however if you are looking for work, you can't exactly make demands saying you will never use them if your group is established and using them.

So all that being said......best case scenario is that they work completely independently. They are responsible for themselves.

 

[Carbocation1]

Straight up, my eyes glazed over as I read your post. What you think our politicians do when you use this same argument?

"I have a study." Boom. CRNAs win.

I've been around long enough on SDN that you should know I'm with you on this issue. But the way your people approach the problem is stupid.

Do some studies. Design them as needed to produce the outcomes you need. Your opponents aren't playing fair, neither should you.

Get with the times, before anesthesiology becomes a historical footnote. You think I really want some nurse in charge of keeping my patient alive while I bleed them?

"anesthesiology becomes a historical footnote"? Wow. Worst case scenario is MDs accept CRNA-level salary, and the MD will definitely get the job over the nurse. CRNAs already make more than many doctors.

There will always be a need the for the perioperative/acute care physician. CRNAs can do most of the monkey procedures but they lack the medical-knowledge base and decision making skills that save lives/prevent bad outcomes.

 

[OnePunchBiopsy]

CRNAs can do most of the monkey procedures but they lack the medical-knowledge base and decision making skills that save lives/prevent bad outcomes.

In more rural areas and growing communities, CRNAs have a stronger grip on anesthesiology practice. The day I decided anesthesia was not for me was the day I overheard 2 docs at my hospital talking about potentially having CRNAs work heart rooms (you know, CABGs with TEE and the works) because changes in hospital policy were going to make some docs on call have to work 48 hours straight.

 

[Dral]

I am an NP. I can tell you this, in this age of Obamacare, and rising medical expenses, hospitals and insurance companies are going to do whatever it takes, to save a buck. 21 states now allow autonomous practice by NPs. In 10 years, it will be 50 states. Do you really think that an insurance company will pay a FP MD $75 for an office visit for txmt of an ear ache, while they can pay the NP $40? Nope.... just follow the money..... That's the way it always has been, and that is the way it always will be. Primary care will be run by NPs, whether the AMA likes it or not.

"I am a nurse who never wanted to become an NP because of bad personal experience. My school NP didn't diagnose my ear infection but common sense tells me that my ear should never hurt that bad... So I went to my primary care physician... I'm unsure if I want to do primary care in medicine in the future, but the quality of care by NPs concerns me so... I do respect nurses who practice good nursing very much."



Sounds like the insurance company theoretically would have had to pay $115 instead of $75 in that person's case.

I think an NP can be trained to handle most things in primary care. I do have some fears about certain knowledge/experience gaps, however.

 

[giantswing]

So what happens when the "independant" crna cant do a surgical airway (they're not trained to do that where i work) and the surgeon is?

 

[NontradCA]

 

[VA Hopeful Dr]

Primary care will be run by NPs, whether the AMA likes it or not.

Doubt it

 

[giantswing]

Presumably you would go ahead and save the patient. Hell, I've dropped more than one chrich in my day...

Riiiiiight... Thats the thing tho. Ethically that's the right thing to do but legally you've just f'ed yourself.

 

[ACSurgeon]

So what happens when the "independant" crna cant do a surgical airway (they're not trained to do that where i work) and the surgeon is?

I don't think anesthesiologists are trained to place surgical airways. I'm sure some anesthesia doctors are capable or have placed surgical airways, but I bet the vast majority aren't exactly trained in this procedure. Haven't met any residents who've done any. I'm sure anesthesia doctors are much better at difficult airway management though.

Independent CRNA = CRNA is liable. Now, in states where CRNAs need MD supervision and the surgeon in the room is (unbeknownst to them) supervising the CRNA, then you'd be liable as the surgeon.

 

[ACSurgeon]

Presumably you would go ahead and save the patient. Hell, I've dropped more than one chrich in my day...

You're military though right? How many orthopedic surgeons feel comfortable surgically placing an airway? Those who are comfortable don't know what they don't know.

In a pinch, anyone can try. If the patient is dying anyway, an attempt is better than no attempt. Also, if it wasn't your airway to begin with, I wonder if you're covered under the Good Samaritan laws.

 

[Darth Doc]

1. Set higher minimum education and training requirements to assure only experienced and well-educated nurses can attain the credential and that it's not so cheap and easy that anyone can do it.

One way to start is requiring that online NP students are monitored during testing to avoid cheating. I know NP students who have an "open note" and "open friend" policy during the week long time frame they have to take their tests. Some will even alternate their tests specifically so they can help each other pass.

 

[cbrons]

Independent CRNA = CRNA is liable. Now, in states where CRNAs need MD supervision and the surgeon in the room is (unbeknownst to them) supervising the CRNA, then you'd be liable as the surgeon.

Yea i found this out recently. Lol! I doubt many surgeons know that.

 

[giantswing]

I don't think anesthesiologists are trained to place surgical airways. I'm sure some anesthesia doctors are capable or have placed surgical airways, but I bet the vast majority aren't exactly trained in this procedure. Haven't met any residents who've done any. I'm sure anesthesia doctors are much better at difficult airway management though.

Independent CRNA = CRNA is liable. Now, in states where CRNAs need MD supervision and the surgeon in the room is (unbeknownst to them) supervising the CRNA, then you'd be liable as the surgeon.

Im in a surgical sub specialty residency, and we were trained to do crics as part of Atls certification. I don't know if anesthesia had to do atls, but i know the crnas said that they do not do surgical airways.

So if we do one on a dying pt haven't we just "assumed" responsibility for the airway from a lawyer standpoint? Even if it was the crnas patient?

And f being the supervising physician. You dont expect anesthesia to operate. Don't expect me to do anesthesia stuff.

 

[ACSurgeon]

Im in a surgical sub specialty residency, and we were trained to do crics as part of Atls certification. I don't know if anesthesia had to do atls, but i know the crnas said that they do not do surgical airways.

So if we do one on a dying pt haven't we just "assumed" responsibility for the airway from a lawyer standpoint? Even if it was the crnas patient?

And f being the supervising physician. You dont expect anesthesia to operate. Don't expect me to do anesthesia stuff.

ATLS teaching is better than nothing, I guess. If you don't routinely operate on the airway (eg tracheotomy) or in the neck, trying to get place a cric in a stressful situation will be challenging. It's challenging regardless. An anesthesia attending who only holds a scalpel to stab the skin during a central placement isn't going to be much better than a CRNA at surgical airway placement because they learned it in ATLS.

My understanding is that if you try to salvage someone's complication and aren't successful, you're not liable as long as you don't do anything outside the standard of care. If a dying patient dies due to failed intubation, you stepping in and attempting a cric isn't the reason they died. So, if you're not the doctor supervising the CRNA, you shouldn't be liable for the airway related death. It's not your airway.

 

[ACSurgeon]

Yea i found this out recently. Lol! I doubt many surgeons know that.

I learned this from sdn posts of court documents where a surgeon's was found liable for the anesthesia related complication because they were the doctor supervising the CRNA. Not something I've learned in my training unfortunately... But this will be something o pay attention to if I go somewhere that doesn't use anesthesia doctors to supervise every CRNA.

 

[IlDestriero]

I learned this from sdn posts of court documents where a surgeon's was found liable for the anesthesia related complication because they were the doctor supervising the CRNA. Not something I've learned in my training unfortunately... But this will be something o pay attention to if I go somewhere that doesn't use anesthesia doctors to supervise every CRNA.

They will deny this is the case, and say that you won't be held liable for their actions, but some courts have disagreed. Time will tell how it pans out.
They will always go after the deepest pockets, and you'll probably always have more than the CRNA.

 

[cbrons]

One way to start is requiring that online NP students are monitored during testing to avoid cheating. I know NP students who have an "open note" and "open friend" policy during the week long time frame they have to take their tests. Some will even alternate their tests specifically so they can help each other pass.

Those tests are probably not relevant to medical practice anyway

 

[TaroBubbleTea]

Those tests are probably not relevant to medical practice anyway

Yea, they are probably tests asking about things like "scope of practice committees" and other ways to indoctrinate NPs to further the lobby's agenda like mindless zombies.

 

[Darth Doc]

Those tests are probably not relevant to medical practice anyway

Nope. Those are pathophysiology, pharmacology, etc.

Not all NP online schools are this lax.

 

[Mad Jack]

It's an interesting point you guys bring up. I think one thing med students, residents and attendings alike are not trained in is the money of medicine. I'd like to think that most of us have the mindset of provide the best care for our patients. Hospital admin, especially those with business backgrounds (aka no medicine background at all), tend to be more about money. If it makes the hospital money, they'll do it. Regardless if it is better for the patient or not.

Ever wonder why you drive on the highway there are signs for coming to x hospitals ED but rarely a primary care office? Ever wonder why all these hospitals have programs to keep heart failure pts out of the ED after a hospitalization that generally last 30 days (you get paid again at 31 days)? It's all about money. Hospitals make 3-4 times the money seeing an average Joe in the ED for their primary care (hence why there is no mass movement for PC by most hospitals). This may all change once we move from fee-for-service to high value care. I have seen some excellent health care models get dissolved because it doesn't make the hospital money.

What you are describing is the same thing. Why have anesthesiologist when you can have a NP do it for the third of the cost (hence the movement we are seeing now)? Same is happening with PC and some fields of surgery with PAs. Unfortunately, money has taken over a field which should probably never been a "for profit" corporation.

Actually, we've got a lot of ads for hospital primary care networks around here, because they use their primary care networks to refer to their specialists. They view it as a cheap method of market capture.

 

[Mad Jack]

They will deny this is the case, and say that you won't be held liable for their actions, but some courts have disagreed. Time will tell how it pans out.
They will always go after the deepest pockets, and you'll probably always have more than the CRNA.

This is exactly why people claiming anesthesiologists will go the way of the dinosaur are completely wrong- without anesthesiologists as a buffer against hospital litigation, hospitals would lose millions in malpractice claims. Comparatively, anesthesiologists running supervision function as a relatively cheap form of insurance.