What is the midlevel situation in CC?

[Brahnold Bloodaxe]

I've thought for a long time that EM was going to be my specialty of choice but I'm becoming increasingly worried about their rapidly expanding residency positions and-importantly-the growing utilization of midlevels in the ED. You now have rural EDs staffed exclusively by NPs and PAs and even the higher volume places are beginning to prefer supplementing their staffing with midlevels over hiring more docs, which is worrisome give the rapidly growing number of residents graduating each year.

CC is similar to the EM lifestyle and if anything the nature of the work appeals to me more than EM, but I've always been put off by having to train 2 extra years. With that said, I'm starting to consider the possibility of doing a CC fellowship depending on how bad the job market in EM gets by the time I'm an attending, so I was curious to see whether I'd be jumping from the frying pan and into the fire as it were when it comes to midlevel encroachment.

I've seen some old threads in this forum discussing critical care fellowships for NPs and other nonsense like that so I was wondering what the situation with midlevels is now in 2017. Do you guys think the potential for encroachment in CC is less than what we're seeing with fields like anesthesia, em, primary care and the like?

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[bashwell]

I've thought for a long time that EM was going to be my specialty of choice but I'm becoming increasingly worried about their rapidly expanding residency positions and-importantly-the growing utilization of midlevels in the ED. You now have rural EDs staffed exclusively by NPs and PAs and even the higher volume places are beginning to prefer supplementing their staffing with midlevels over hiring more docs, which is worrisome give the rapidly growing number of residents graduating each year.

CC is similar to the EM lifestyle and if anything the nature of the work appeals to me more than EM, but I've always been put off by having to train 2 extra years. With that said, I'm starting to consider the possibility of doing a CC fellowship depending on how bad the job market in EM gets by the time I'm an attending, so I was curious to see whether I'd be jumping from the frying pan and into the fire as it were when it comes to midlevel encroachment.

I've seen some old threads in this forum discussing critical care fellowships for NPs and other nonsense like that so I was wondering what the situation with midlevels is now in 2017. Do you guys think the potential for encroachment in CC is less than what we're seeing with fields like anesthesia, em, primary care and the like?

Just my opinion as a lowly resident:

1) I forget if I mentioned this to you in your other thread, but from what I can tell the future of critical care looks promising (e.g., more ICUs becoming closed and thus needing more physicians trained in critical care). If anything, there will be more than enough room for both physicians and midlevels in the ICU.

2) Also, patients and their family members can see, meet, and interact with ICU physicians quite a bit if they want. There's plenty of communication between critical care physicians, patients, and families in the ICU. That's different from (for example) anesthesia where most patients don't really get to interact with anesthesiologists except for a few minutes before their surgery and maybe in the PACU if they're awake by then (and at most in a pre-op clinic) and so don't know that anesthesiologists are even doctors let alone "their" doctors. They think the surgeon is "their" doctor. The fact that patients and their families know the ICU physician is their doctor means quite a lot in terms of future job security or safety.

3) Related to #2, patients, their families, and friends won't likely want to have nurses or other midlevels in charge of their loved ones especially while their loved ones are in a "critical" state. Patients and their families and friends will want to talk to the doctor, not a nurse or PA.

4) The nature of treating and managing a patient in the ICU is sufficiently complex (in terms of the medical science) that I don't see a midlevel being able to do so any time soon. You can teach a midlevel to do procedures, but there's a lot more to critical care medicine than procedures.

5) So, no, personally, I don't think midlevels will be able to encroach on ICU physicians any time soon, not like they've done in anesthesia. And I could be wrong, but my guess is most other specialties have probably taken the lessons of what's happened with anesthesia and CRNAs to heart that they will likely fight hard not to repeat the same mistake with midlevels in their specialties.

6) Of course, all this is different from whether you will actually enjoy working in the ICU. That's more of a personal decision. But I don't think the lifestyle in the ICU is any better than the lifestyle in the ED overall. Although the environment is usually much calmer and the pace of seeing ICU patients a whole lot better than the ED, in my experience.

 

[AdmiralChz]

Bashwell raises some solid points above, and I largely agree with his analysis.

The trouble is at my residency program we had hyper aggressive PA/NPs that staffed the surgical ICUs. We have a "fellowship" for both NPs and PAs in surgical critical care, and they frequently came running up just as we were about to stick for a central line or intubate saying they needed numbers for credentialing. It wasn't until the end of residency until I made it my missions to shove off.

We had an ICU fellowship, and with the SICUs mostly staffed by surgeons the attendings would come for rounds only and then disappear theoretically leaving the ICU fellow in charge. We had a very weak program for a variety of reasons and if we had a weak fellow (or worse, a clueless MICU rotator who was gone half the day for clinic) then the NPs would take the fellow phone and be "acting fellow" for the day. They frequently ran afternoon rounds by themselves as well without MD involvement. I had to run changes in management in my patients by them, which was pretty freaking terrible.

While I understand where Bashwell is coming from, in my (limited) experience the surgeon takes primary responsibility in theory for patients and family discussions - while it is important to have solid critical care nearby providing support I can envision a day where the surgeon has those end-of-life/palliative discussions without a CCM physician anywhere nearby and more with just a CCM PA/NP to boss around how he or she likes postoperative or complication management. Personally, I would be worried about it going forward for SICUs. I think CVICUs, MICUs and Neuro ICUs have sufficiently complex and sick patients that such "full practice authority" won't happen anytime soon.

TL;DR: I had a really bad experience with over-confident, rude and full practice-seeking NP/PAs at my residency program. I don't believe this is the norm around the country by any stretch but I know of other places with similar stories.

Here are some links for NP fellowships at big name institutions for reference (my residency program not among them):

Surgical & Critical Care Nurse Practitioner Fellowship - University of California, San Francisco - - Surgical & Critical Care Nurse Practitioner Fellowship

AGACNP Critical Care Fellowship | DNP | School of Nursing | Vanderbilt University

MCW: NP and PA Critical Care Fellowship

St. Luke's - Critical Care & Emergency Medicine Advanced Practitioner Fellowship

Emory Critical Care Center NP/PA Post Graduate Residency | Woodruff Health Sciences Center | Emory University

Nurse Practitioner or Physician Assistant Critical Care Fellowship (Minnesota) - Mayo Clinic School of Health Sciences - Mayo Clinic

UPMC Critical Care Medicine Advanced Practice Provider Residency | University of Pittsburgh Department of Critical Care Medicine

 

[CCM-MD]

From my experience midlevels function like interns in ICUs of non-teaching hospitals. Good at gathering information and following through with instructions. They generally know the EMR and hospital systems well which makes them efficient at getting consultants involved, writing orders, and following up with things that need to be done. I think they have a role in the ICU, especially in community hospitals which don't have residents and fellows. But I wouldn't be worried about them replacing ICU physicians.

 

[tartesos]

Mid levels, running rounds and icu should not be pronounced in the same sentence, what blasphemy is this?!?!?

Esto se jodio.



Sent from my iPhone using SDN mobile app

 

[deleted171991]

The "situation" is that some good brands are actively developing CCM residencies/fellowships for APRNs/PAs, because they have trouble finding enough worker bees among physicians. So, while still not a big problem, expect the midlevels to become one in 10-15-20 years, as in many other specialties.

 

[MSmentor018]

Here's a view from downstairs looking up. I am an EM guy, former RN, medic. the op is right, there's definitely a successful move among the NP organization for indep practice and to fill the gap left by physicians. At my shop, outside the residents it's heavily midlevel driven. mainly the discussion has been the rural areas but its' all over now. the govt and american people want everything cheaper and faster....even if it's coming from someone with 1/1000 of clinical training (that's a true statistic). Many places don't offer midlevel CC training, like anything else all those positions are OJT. You can only hope they've had some advanced "fellowship" training before starting. All of my NP friends just graduated and started in the unit. The money's good. Sure there's a little hand holding in the beginning and some are more indep than others. When they're tired of it, they just move on to another gig cards, trauma, ortho, ob...etc. I work in 3 rural ED's (only 1 NP in the unit) and at a level I with 72 bed ICU mix of trauma, medicine, neuro, vascular staffed by 1 private medicine ICU attending w plenty of NP's and 1 academic attending w residents. There's also neuro, trauma, cardiothroacic/vascular NP's that also cover. When I admit to the unit sometimes I get the doc/resident, mostly not. so are they encroaching the ICU...you betcha

 

[CCM-MD]

Here's a view from downstairs looking up. I am an EM guy, former RN, medic. the op is right, there's definitely a successful move among the NP organization for indep practice and to fill the gap left by physicians. At my shop, outside the residents it's heavily midlevel driven. mainly the discussion has been the rural areas but its' all over now. the govt and american people want everything cheaper and faster....even if it's coming from someone with 1/1000 of clinical training (that's a true statistic). Many places don't offer midlevel CC training, like anything else all those positions are OJT. You can only hope they've had some advanced "fellowship" training before starting. All of my NP friends just graduated and started in the unit. The money's good. Sure there's a little hand holding in the beginning and some are more indep than others. When they're tired of it, they just move on to another gig cards, trauma, ortho, ob...etc. I work in 3 rural ED's (only 1 NP in the unit) and at a level I with 72 bed ICU mix of trauma, medicine, neuro, vascular staffed by 1 private medicine ICU attending w plenty of NP's and 1 academic attending w residents. There's also neuro, trauma, cardiothroacic/vascular NP's that also cover. When I admit to the unit sometimes I get the doc/resident, mostly not. so are they encroaching the ICU...you betcha

There's no denying midlevels are already working in ICUs and have a role but it is not going to be replacing the critical care physician. A midlevel working at the level of an intern/resident is not encroaching on critical care physicians. Predicting the future is impossible but I doubt there will ever be a time where a midlevel will be managing a typical ICU patient in shock/respiratory failure with multi-system involvement without a critical care physician.

In addition, this would be the complete opposite of what the current trend is. Especially considering there has been a giant push for high intensity 24 hour intensivist staffing of ICUs in the last 5-10 years due to the Leapfrog initiative. There are also numerous studies showing lower costs and better outcomes when patients are managed by fellowship trained intensivists. I can speak for the area I live in, where there has been pretty drastic transition in the last 5-10 years from internists and private pulmonary groups running open ICUs to in house intensivists even at smaller hospitals. So going from a critical care physician to an independent midlevel will be a complete reverse move and is not going to happen.

The ICU is not going to go the way of anesthesia, ER, hospital medicine, or outpatient medicine. I don't mean to offend anyone, but I can imagine that a nurse/PA without physician oversight could see a patient in the ER with acute bronchitis/UTI/diarrhea, manage a patient on the floor with an uncomplicated pneumonia, maybe even safely administer anesthesia to a patient undergoing a lap chole. Sure there are some uncomplicated DKA type patients in the ICU but a majority of the patients are not.

Lets look at it from a patient's family's perspective. Mary may be ok with her grandpa getting antibiotics for a "stomach bug" from a nurse/PA in the ED. Mary might even be ok that grandpa is getting his gallbladder removed with a CRNA administering anesthesia because she doesn't know/understand the role of a anesthesiologist. But when grandpa can't get off the vent in the ICU after a post-operative complication from his cholecystectomy, I am pretty sure Mary is not going to be happy finding out that a nurse/PA is independently caring for her grandpa. I suspect Mary is going to want to speak to a physician.

 

[MSmentor018]

There's no denying midlevels are already working in ICUs and have a role but it is not going to be replacing the critical care physician. A midlevel working at the level of an intern/resident is not encroaching on critical care physicians. Predicting the future is impossible but I doubt there will ever be a time where a midlevel will be managing a typical ICU patient in shock/respiratory failure with multi-system involvement without a critical care physician.

In addition, this would be the complete opposite of what the current trend is. Especially considering there has been a giant push for high intensity 24 hour intensivist staffing of ICUs in the last 5-10 years due to the Leapfrog initiative. There are also numerous studies showing lower costs and better outcomes when patients are managed by fellowship trained intensivists. I can speak for the area I live in, where there has been pretty drastic transition in the last 5-10 years from internists and private pulmonary groups running open ICUs to in house intensivists even at smaller hospitals. So going from a critical care physician to an independent midlevel will be a complete reverse move and is not going to happen.

The ICU is not going to go the way of anesthesia, ER, hospital medicine, or outpatient medicine. I don't mean to offend anyone, but I can imagine that a nurse/PA without physician oversight could see a patient in the ER with acute bronchitis/UTI/diarrhea, manage a patient on the floor with an uncomplicated pneumonia, maybe even safely administer anesthesia to a patient undergoing a lap chole. Sure there are some uncomplicated DKA type patients in the ICU but a majority of the patients are not.

Lets look at it from a patient's family's perspective. Mary may be ok with her grandpa getting antibiotics for a "stomach bug" from a nurse/PA in the ED. Mary might even be ok that grandpa is getting his gallbladder removed with a CRNA administering anesthesia because she doesn't know/understand the role of a anesthesiologist. But when grandpa can't get off the vent in the ICU after a post-operative complication from his cholecystectomy, I am pretty sure Mary is not going to be happy finding out that a nurse/PA is independently caring for her grandpa. I suspect Mary is going to want to speak to a physician.

I don't think they'll get complete total solo practice...at least I hope not. in rural areas of georgia the CRNA's do. In the unit they'll never replace, you always need a physician to oversee and be the scapegoat. Some doc's name has to be on the chart or "available for consultation". And for the seriously sick ones that go to the unit, the doc usually takes the case but that line is getting blurred daily. Ours is being pushed to do more and more complicated cases. So much so the PA society has allowed them to do procedures like chest tubes without supervision. I too believe physicians have a better outcome but sccm believes the mid level role out performs residents. http://www.clinicaladvisor.com/news...oner-physician-assistant-care/article/394229/
this type of research, whether flawed or not extends to other specialties too.

There's always a balance between leapfrog, press ganey, (there's 1 more thing I can't recall) and costs. Absolutely having a closed icu is much better on pt outcome than having the ED doc come upstairs or RN calling the ICU doc at home but staffing that costs money, and we all know how groups (esp contract management groups) feel about spending money. As the "DNP website says, we're the obvious solution!". unfortunately the family perspective or even the pt is never brought up when talking about encroachment, money, outcomes. Pt's SHOULD always meet the ICU physician preferably at the beginning of the assessment...or did they. It's hard for pt's to understand the multitude of acronyms and titles, for example: "I am DR JANE, arnp-c, msn, phd, bsn"

 

[Nephro critical care]

NPs usually run when SHTF. And since SHTF all the time in critical care they will never be running the show. I always listen to NPs because they will pick up on some things I will overlook like someone's home medications which were held or duration of antibiotics etc.
But usually they won't be able to figure out what's killing the patient or be able to do that crash line/ intubation.

 

[CCM-MD]

There might be a few midlevels who can tune/line a patient, which I am ok with. You can probably teach a monkey how to do a procedure. But you probably can't teach a majority of monkeys enough physiology to make a typical ICU patient better. There are more than enough sufficiently complex patients in the ICU to prevent a chimpanzee takeover.

 

[MSmentor018]

There might be a few midlevels who can tune/line a patient, which I am ok with. You can probably teach a monkey how to do a procedure. But you probably can't teach a majority of monkeys enough physiology to make a typical ICU patient better. There are more than enough sufficiently complex patients in the ICU to prevent a chimpanzee takeover.

there are already ED's only staffed with midlevels and some attending is at home signing charts/available for consults. the OR (surgery) and true critical ill IS the final line in the sand. chimps will never completely take over, just give the big ape a lot of headaches

 

[NYCGuy86]

NP/PA critical care fellowships:

Surgical & Critical Care Nurse Practitioner Fellowship - University of California, San Francisco - - Surgical & Critical Care Nurse Practitioner Fellowship
Emory Critical Care Center NP/PA Post Graduate Residency | Woodruff Health Sciences Center | Emory University
UPMC Critical Care Medicine Advanced Practice Provider Residency | University of Pittsburgh Department of Critical Care Medicine
http://www.hopkinsmedicine.org/surgery/education/pacc_residency/description.html
Nurse Practitioner or Physician Assistant Critical Care Fellowship (Minnesota) - Mayo Clinic School of Health Sciences - Mayo Clinic
APP Fellowship Program in Critical Care Medicine - Residencies and Fellowship Opportunities - Information for Residents, Students and Professional Education - Department of Surgery - University of Rochester Medical Center

To name a few.

 

[SurfingDoctor]

Relevant and released just this month in CCM:
Acute Care Nurse Practitioners and Physician Assistants in... : Critical Care Medicine

 

[AdmiralChz]

Relevant and released just this month in CCM:
Acute Care Nurse Practitioners and Physician Assistants in... : Critical Care Medicine

"The use of structured training programs in critical care for NPs and PAs advances knowledge and skills in these providers. When integrated as professional staff and layered with around-the-clock resource physicians (either on-site or remote e-ICU intensivists), these practitioners may safely and effectively perform at the upper boundaries of their scope of practice. Such teamwork across the intensivist-led, multiprofessional ICU yields patient care with high access, high quality, and high value (32)."

Sure sounds like advocating a very similar "collaborative" model to some systems use with CRNAs. As I said above we had some hyper-aggressive mid-levels at my residency program, I expect to see this continue to spread in the future - especially if CCM programs continue to struggle to fill their positions (speaking from anesthesia/surgery/EM programs, I do not know the landscape or data from IM CC or peds CC) leading to less providers.

 

[SurfingDoctor]

"The use of structured training programs in critical care for NPs and PAs advances knowledge and skills in these providers. When integrated as professional staff and layered with around-the-clock resource physicians (either on-site or remote e-ICU intensivists), these practitioners may safely and effectively perform at the upper boundaries of their scope of practice. Such teamwork across the intensivist-led, multiprofessional ICU yields patient care with high access, high quality, and high value (32)."

Sure sounds like advocating a very similar "collaborative" model to some systems use with CRNAs. As I said above we had some hyper-aggressive mid-levels at my residency program, I expect to see this continue to spread in the future - especially if CCM programs continue to struggle to fill their positions (speaking from anesthesia/surgery/EM programs, I do not know the landscape or data from IM CC or peds CC) leading to less providers.

Pediatric Critical Care is getting more competitive for spots each year (probably related to the debt to potential earning ratio many trainee struggle with). That being said, every major PICU I've worked at has employed NPs and PAs. But PICUs don't spring up overnight, so I don't think there is a lot of room for NP and PA growth in the PICU environment from a clinical standpoint. I could be wrong, but it doesn't seem likely at this point. Maybe in the eICU model the paper refers to, but I have no idea if that model of care would ever be acceptable in pediatrics. There is just a different standard of physician accessibility.

 

[CCM-MD]

"The use of structured training programs in critical care for NPs and PAs advances knowledge and skills in these providers. When integrated as professional staff and layered with around-the-clock resource physicians (either on-site or remote e-ICU intensivists), these practitioners may safely and effectively perform at the upper boundaries of their scope of practice. Such teamwork across the intensivist-led, multiprofessional ICU yields patient care with high access, high quality, and high value (32)."

Sure sounds like advocating a very similar "collaborative" model to some systems use with CRNAs. As I said above we had some hyper-aggressive mid-levels at my residency program, I expect to see this continue to spread in the future - especially if CCM programs continue to struggle to fill their positions (speaking from anesthesia/surgery/EM programs, I do not know the landscape or data from IM CC or peds CC) leading to less providers.

IM based Pulm/CCM and CCM programs are competitive and increasing in popularity in recent years. As far as I know there aren't any ER based CCM fellowships. Anesthesia and Surgery based fellowships seem to have some open spots every year but unless they start taking NPs/PAs I don't think this changes anything. As the CRNA movement continues to suck the life out of anesthesiology and CCM compensation rises, I suspect more will train in CCM.

I stand by what I said previously. The "collaborative model" is present in nearly every lucrative specialty. There's midlevels doing consults in procedural medical specialties like GI/cards and surgical subspecialties. They function as data gatherers, not writers and bodies that can follow instructions with some direction. This is how they function in CCM also. By the way, there's NP GI fellowships train them to perform colonoscopies independently. There is also at least one study I know of that demonstrated that PAs can perform diagnostic cardiac caths safely. See below.

Screening Colonoscopy: A New Frontier for Nurse Practitioners
Mayo Cardiology Nurse Practitioner Fellowship
Trained and supervised physician assistants can safely perform diagnostic cardiac catheterization with coronary angiography

Midlevel encroachment is everywhere. I'm not worried about it in CCM.

 

[bashwell]

I think the key is to become indispensable. No matter what specialty that is. A physician can be seen as indispensable in many different ways. Here are some examples but there are probably a lot of other examples:

1) That could be by getting (as Liam Neeson would say) "a particular set of skills" that's hard if not impossible for midlevels to reproduce let alone replace. This can be done by doing a specialty or fellowship that midlevels can't touch. I think this applies to surgical specialties in general as well as to critical care medicine. I think this applies to several anesthesiology fellowships.

2) That could be by having patients think of you as "their doctor." For example, even though there are a lot of midlevels in oncology who can do a lot of the work to help facilitate the work of oncologists, and even though there's the matter of protocolization to deal with to some extent in oncology, most patients will still follow their oncologists to the ends of the earth no matter what. If patients are willing to follow you anywhere, then you have a lot more control over what you want or don't want to do, and you have a lot more pull with others (e.g., hospital admins). I think all IM subspecialties including critical care fit here too.

3) That could be by not being dependent on others such as hospital systems and their bean counters, but being in a specialty where it's easier to set up your own shop, so that hospitals and groups see you as a pot of gold and thus come to you for business, rather than the other way around. PCPs fit here, but then again you have to enjoy the work of being a PCP. Same with psych. Same with derm. Obviously several surgical subspecialties fit here.

4) As I once heard an older physician say, if you can't beat them, join them. You could sit on important hospital committees, or even become a hospital admininstrator, and thus have a big say in the decisions of the hospital, and thus use your influence to benefit your specialty.

 

[deleted171991]

There's no denying midlevels are already working in ICUs and have a role but it is not going to be replacing the critical care physician. A midlevel working at the level of an intern/resident is not encroaching on critical care physicians. Predicting the future is impossible but I doubt there will ever be a time where a midlevel will be managing a typical ICU patient in shock/respiratory failure with multi-system involvement without a critical care physician.

In addition, this would be the complete opposite of what the current trend is. Especially considering there has been a giant push for high intensity 24 hour intensivist staffing of ICUs in the last 5-10 years due to the Leapfrog initiative. There are also numerous studies showing lower costs and better outcomes when patients are managed by fellowship trained intensivists. I can speak for the area I live in, where there has been pretty drastic transition in the last 5-10 years from internists and private pulmonary groups running open ICUs to in house intensivists even at smaller hospitals. So going from a critical care physician to an independent midlevel will be a complete reverse move and is not going to happen.

The ICU is not going to go the way of anesthesia, ER, hospital medicine, or outpatient medicine. I don't mean to offend anyone, but I can imagine that a nurse/PA without physician oversight could see a patient in the ER with acute bronchitis/UTI/diarrhea, manage a patient on the floor with an uncomplicated pneumonia, maybe even safely administer anesthesia to a patient undergoing a lap chole. Sure there are some uncomplicated DKA type patients in the ICU but a majority of the patients are not.

Lets look at it from a patient's family's perspective. Mary may be ok with her grandpa getting antibiotics for a "stomach bug" from a nurse/PA in the ED. Mary might even be ok that grandpa is getting his gallbladder removed with a CRNA administering anesthesia because she doesn't know/understand the role of a anesthesiologist. But when grandpa can't get off the vent in the ICU after a post-operative complication from his cholecystectomy, I am pretty sure Mary is not going to be happy finding out that a nurse/PA is independently caring for her grandpa. I suspect Mary is going to want to speak to a physician.

It depends on the intensivists. Where I work as an anesthesiologist, they are sooo weak I literally hate dealing with ICU patients (and I am board-certified in CCM). Every time I go there for an intubation, I see another proof of incompetence from a different intensivist (simple stuff, not rocket science). I doubt that they are better than some of the APRNs I worked with during my fellowship. And I wouldn't be surprised if this the case for many community hospital ICUs.

I foresee CCM going the way of anesthesia midlevel-wise, with all these lazy, incompetent or overworked docs who just don't take the time to do their job well, or practice 10-20 year-old critical care. Especially if the hospitals are too cheap to pay the truly good intensivists well.

 

[CCM-MD]

It depends on the intensivists. Where I work as an anesthesiologist, they are sooo weak I literally hate dealing with ICU patients (and I am board-certified in CCM). Every time I go there for an intubation, I see another proof of incompetence from a different person (simple stuff, not rocket science). I doubt that they are better than some of the APRNs I worked with during my fellowship. And I wouldn't be surprised if this the case for many community hospital ICUs.

I foresee CCM going the way of anesthesia midlevel-wise, with all these lazy, incompetent or overworked docs who just don't take the time to do their job well, or practice 10-20 year-old critical care. Especially if the hospitals are too cheap to pay the truly good intensivists well.

The fact that you are going to the ICU for intubations speaks for the quality of the intensivists and how things are set up at your institution.

I don't see CCM going the way of anesthesia - even if it does happen its probably going to take a good 15-20 years before things get like they are currently in anesthesia. Many other specialties are likely to get affected before CCM. Plus if you ignore the midlevel issue, things in anesthesiology aren't so bad right now. Anesthesiologists remain highly compensated and seem to have no trouble finding jobs in the current state of things.

 

[MSmentor018]

IM based Pulm/CCM and CCM programs are competitive and increasing in popularity in recent years. As far as I know there aren't any ER based CCM fellowships..

very few but there around. I think baltimore and pitt has it. usf in tampa started one 3 yrs ago. only 1 spot/yr.

 

[swamprat]

I didn't read this thread but EM for the short term at least (~10 years) is hot. Tons of jobs. Recruiters email me daily, they want BE/BC docs only. I wouldn't avoid EM worried about mid level encroachment. I also think the majority of mid levels do not want to be the boss and def do not have the skill necessary to do my job.

 

[Psai]

Bashwell raises some solid points above, and I largely agree with his analysis.

The trouble is at my residency program we had hyper aggressive PA/NPs that staffed the surgical ICUs. We have a "fellowship" for both NPs and PAs in surgical critical care, and they frequently came running up just as we were about to stick for a central line or intubate saying they needed numbers for credentialing. It wasn't until the end of residency until I made it my missions to shove off.

We had an ICU fellowship, and with the SICUs mostly staffed by surgeons the attendings would come for rounds only and then disappear theoretically leaving the ICU fellow in charge. We had a very weak program for a variety of reasons and if we had a weak fellow (or worse, a clueless MICU rotator who was gone half the day for clinic) then the NPs would take the fellow phone and be "acting fellow" for the day. They frequently ran afternoon rounds by themselves as well without MD involvement. I had to run changes in management in my patients by them, which was pretty freaking terrible.

While I understand where Bashwell is coming from, in my (limited) experience the surgeon takes primary responsibility in theory for patients and family discussions - while it is important to have solid critical care nearby providing support I can envision a day where the surgeon has those end-of-life/palliative discussions without a CCM physician anywhere nearby and more with just a CCM PA/NP to boss around how he or she likes postoperative or complication management. Personally, I would be worried about it going forward for SICUs. I think CVICUs, MICUs and Neuro ICUs have sufficiently complex and sick patients that such "full practice authority" won't happen anytime soon.

TL;DR: I had a really bad experience with over-confident, rude and full practice-seeking NP/PAs at my residency program. I don't believe this is the norm around the country by any stretch but I know of other places with similar stories.

Here are some links for NP fellowships at big name institutions for reference (my residency program not among them):

Surgical & Critical Care Nurse Practitioner Fellowship - University of California, San Francisco - - Surgical & Critical Care Nurse Practitioner Fellowship

AGACNP Critical Care Fellowship | DNP | School of Nursing | Vanderbilt University

MCW: NP and PA Critical Care Fellowship

St. Luke's - Critical Care & Emergency Medicine Advanced Practitioner Fellowship

Emory Critical Care Center NP/PA Post Graduate Residency | Woodruff Health Sciences Center | Emory University

Nurse Practitioner or Physician Assistant Critical Care Fellowship (Minnesota) - Mayo Clinic School of Health Sciences - Mayo Clinic

UPMC Critical Care Medicine Advanced Practice Provider Residency | University of Pittsburgh Department of Critical Care Medicine

That's really sad. For us, the midlevels are basically on the level of interns and do a lot of the notes, phone calls but never make higher management decisions. Ever.

 

[Nephro critical care]

What I am more interested in: Is there a way I can bill on a NP critical care note ? I know that an NP can bill at 85% of what a physician can. But I can't take over her CC note if I write an addendum. If she writes a subsequent level 3 note on a patient I can write an addendum and bill on her note. That's at least what my hospital tells me.

 

[AdmiralChz]

That's really sad. For us, the midlevels are basically on the level of interns and do a lot of the notes, phone calls but never make higher management decisions. Ever.

It was horrible, not the case everywhere thankfully but I worry this sort of stuff could spread.

 

[G-Man82]

What I am more interested in: Is there a way I can bill on a NP critical care note ? I know that an NP can bill at 85% of what a physician can. But I can't take over her CC note if I write an addendum. If she writes a subsequent level 3 note on a patient I can write an addendum and bill on her note. That's at least what my hospital tells me.

I think you can. You just gotta document what you did and managed and make all the usual statements that the patient is critically ill and note however many minutes of non-overlapping CC time was spent.

Or just write a separate note. It doesn't have to be a floor style complete note.


Sent from my iPhone using SDN mobile

 

[cbrons]

Depressing

 

[Mad Jack]

I've thought for a long time that EM was going to be my specialty of choice but I'm becoming increasingly worried about their rapidly expanding residency positions and-importantly-the growing utilization of midlevels in the ED. You now have rural EDs staffed exclusively by NPs and PAs and even the higher volume places are beginning to prefer supplementing their staffing with midlevels over hiring more docs, which is worrisome give the rapidly growing number of residents graduating each year.

CC is similar to the EM lifestyle and if anything the nature of the work appeals to me more than EM, but I've always been put off by having to train 2 extra years. With that said, I'm starting to consider the possibility of doing a CC fellowship depending on how bad the job market in EM gets by the time I'm an attending, so I was curious to see whether I'd be jumping from the frying pan and into the fire as it were when it comes to midlevel encroachment.

I've seen some old threads in this forum discussing critical care fellowships for NPs and other nonsense like that so I was wondering what the situation with midlevels is now in 2017. Do you guys think the potential for encroachment in CC is less than what we're seeing with fields like anesthesia, em, primary care and the like?

Why are you so scared of midlevels? It's fear to the point of irrationality.

 

[Nephro critical care]

NP are your friends/helpers when it comes to attending practice. Practically speaking in practice in CC you will be seeing 10-18 pts a day . If you are lucky to be in a residency program and have a senior + 2/3 juniors then you don't need NPs.
But most of us dont have residents as attending school and that's where the NP are your help. A census of 15 with 3-6 admits as attending would be brutal. But with an NP on in the day to see 5-7 pts , move some people out and take some of the pages it is still doable.

 

[deleted171991]

Here is the midlevel situation in critical care and its future:
Buchman- The next generation of critical care | University of Maryland

Besides the assembly lane mentality (at one point, I felt like I was watching a business presentation about M&A), the scariest thing is when he points out that, soon, the letters after your name won't matter, just your role on the team. And this is coming from one of the big academic centers, in conjunction with Medicare. Already, the number of American APPs equals the number of intensivists! You can train somebody to do 90% of what a physician does in one third of a time, and that includes a "residency". It will end up being worse than anesthesia, with physicians supervising a lot of midlevels and a ton of beds (hint: eICU), while playing coach, firefighter and, especially, scapegoat for lawsuits. Because it's much cheaper than just hiring more intensivists and incentivizing them properly; that will never happen.

I know that other specialties have similar problems, but there are specialties where you are just not simply the hospital's bitch, while working your butt off with really sick patients. I honestly feel that the incentives are just not there anymore for the stressful intensive specialties. I would even argue that people will be happier as generalists than with a CCM fellowship, while not having wasted 200K-600K on it. People should just put that money in the bank and let it grow for 25-30 years. Make hay while the sun still shines. Had I watched this 3 years ago, I wouldn't have done the fellowship.

 

[deleted171991]

Why are you so scared of midlevels? It's fear to the point of irrationality.

I think it's very rational. There is nothing that exposes one to malpractice more than covering a bunch of midlevels.

 

[CCM-MD]

Interesting video. I've known about Emory's eICU study with CMS for quite some time now. Main objective of it was to get CMS to start paying for eICU. Can't bill critical care time for patient's seen remotely currently. The "NextGen of critical care" as described in that video is many years away. We still have hospitals running on paper charts! And I'm not talking about a tiny hospital in a rural area, I'm talking about at least 2 large level 1 trauma centers in NYC. This is almost at the level of the occasional talk you see on the radiology forum - "artificial intelligence" replacing radiologists reading imaging. Its impossible to predict the future.

"It will end up worse than anesthesia". Anesthesiologists remain highly compensated - MGMA 2016 Median $454,700 growth of 4.6% since prior year with a pretty good job market from what I hear from my colleagues. Intensivists remain in high demand and this is going to stay this way for the foreseeable future.

 

[psychbender]

While interviewing for jobs, I was at an academic medical center which has an NP 'fellowship' in critical care. I happened to speak to the head NP there about how they function (since it varies so much by state and institution, ours are like perpetual junior residents that don't do procedures), and she mentioned that they do all of their own procedure (airways, lines, thoracentesis, paracentesis, etc), make the management decisions, and work fully independently. I know that they have an attending on the services covered by these NPs (no or very rare residents on those teams), and asked when she feels the need to call the attending regarding change in patient status or for help. She scoffed, and replied that there is nothing that the attending could add that she couldn't already do, and if the patient was that sick, they need a surgeon. Maybe I'm just really depressed right now, but I'm with FFP on this. If I had known that this is how far we already were on the road to independent midlevels in the unit, I may have stayed a general anesthesiologist, or done CT.

 

[deleted171991]

Where I trained, it wasn't that bad, but it wasn't far from it. As the on-call fellow, I was the coach (the "resource") for the APP team. So this is already happening.

Coming from anesthesia, where there has been a lot of pessimism for years, I do realize the limits of trying to predict the future. So I have learned that there are two components to it: the technology-dependent and -independent parts. The part that is technology-dependent is futurology. AI helping out etc. We cannot predict when it will happen, just that it will happen. In 10-20-50 years, who knows when. So I don't really care about that part.

The technology-independent component depends a lot on management and Medicare. Now that part I have seen happening with clockwork precision. What management wants, management gets. These are also pretty patient individuals, who will take a decade to build something they think could save them a lot of money (because that money pays for their salaries and bonuses). This part is what scares me. They basically went from zero to 10,000 APPs (which equals the number of intensivists) in the ICU in about a decade. (I have seen the same crap in anesthesia, zero to metastatic cancer, and it's not nice.) I also know the APP mentality, having worked with them; it's very close to what @psychbender described above. I have had some of them push back when I wanted to change their therapeutic plan, the same way militant CRNAs do. I have even been reported for refusing to teach their students advanced critical care concepts. And APPs have just become independent in the VA, which will create a huge precedent in 5-10 years.

Again, watch that video to understand how management and Medicare think. The fact that there is a shortage of intensivists may be a good thing for us short-term, but long-term (and I mean only like 10 years) these people are working hard at minimizing the role of the intensivist (so there will actually be too many of us, the same way there are already too many anesthesiologists in certain parts of the country). Those eICU centers are popping up like mushrooms, and every such center steals the job of an intensivist for every 10 patients it covers. Dr. Buchman points out that a critical care APP can be trained much faster and can do 90% of what an intensivist does. He also points out that salaries are a big component of ICU costs (read between the lines). The only limiting factor to how fast we will be replaced is how fast they can crank out midlevels. I have already seen this in anesthesia. The hospitals are not on your side, not by a mile. They want you to "supervise" and teach midlevels for years so that, at one point, those midlevels can function independently (that's the part they don't tell you). Dr. Buchman is pretty honest about this, when he points out that he won't need intensivists to fix hypoglycemia, he will need them to write protocols (what he calls systems design, or such).

Those MGMA numbers @CCM2017 has quoted are beautiful on paper, just almost inexistent in the parts of the country where CRNAs are multiplying like bacteria (e.g. East Coast). I have yet to meet an employed general anesthesiologist whose entire package comes even close to 400K in my area, and that's for 60+ hours of work. There is already a huge difference in income and career opportunities between the areas with few Anesthesia Care Team practices and those where ACT is predominant. So, as long as nursing schools are cranking out midlevels, this will get only worse. The major barrier is not medical knowledge or malpractice (management types couldn't care less about either), it's the production of midlevels, which is slowly taking industrial proportions. While searching for a post-fellowship job, I was told multiple times that the only reason they were looking for an anesthesiologist was the CRNA shortage. In 10 years, the ICU APPs will do to critical care what CRNAs have done and are doing to anesthesia, with full management support.

So watch that video and learn. Anything management wants and is not limited by current technology will happen. In a decade or less. Why? Money! If you are an internist, do yourself a favor and stay in those subspecialties where patients can still choose their doctor. Otherwise, if you think hospitalists are a miserable bunch, just wait to see the intensivists in 10 years or so.

Doom and gloom... I know. Whatever you do and/or believe, just make sure your head is not in the sand.

 

[AdmiralChz]

It's sad to see this happening at other places, I hate to see my comments validated but I'd be worried about CCM. I've already expansively posted above at my program, but it still makes my blood boil thinking back to SICU rounds when the attending/fellow made a management decision and the PA/NP rolled their eyes and did the exact opposite. "I am here all day paying attention to the patients and dealing with emergencies on my own, I don't need help."

Sound familiar? Yikes.

 

[AdmiralChz]

I also think this could more rapidly get out of hand - the CRNA issue is out there and state/national societies are doing a reasonable job at keeping things controlled for now (and have for a while).

I don't know if there is any national/state societies actively working against the issue presented here, certainly not in an effective way. This has the potential to get out of hand Quickly as FFP alluded to. PAs will join the howl soon enough as well, adding another layer to the problem (especially if they adopt the new moniker "Physician Associate" which is almost laughable).

 

[deleted171991]

PAs will join the howl soon enough as well, adding another layer to the problem (especially if they adopt the new moniker "Physician Associate" which is almost laughable).

If??? There is no If. When places like Yale graduate "Physician Associates", you know how the wind is blowing.

 

[Carbocation1]

If??? There is no If. When places like Yale graduate "Physician Associates", you know how the wind is blowing.

So what is the future role of physicians, in your opinion? Mid-levels are taking over clinical duties in ALL specialties. It's only a matter of time when greedy, old surgeons train mid-levels to do basic operations (already happening at my institution). How hard is it to do orthopedic carpentry or urologic plumbing? Ivory tower centers would LOVE the extra $$$ from training Certified Registered Nurse Operators with DNP degrees.

 

[Ttan]

Aren't surgical ICUs easier to run by midlevels than other types of ICU? It seems more about supportive care than diagnostic care.

 

[deleted171991]

Aren't surgical ICUs easier to run by midlevels than other types of ICU? It seems more about supportive care than diagnostic care.

I concur. I have always wondered why hospitals employ intensivists in open ICUs, instead of just giving the surgeon an APRN in the ICU, to be his puppet. When I was a fellow, I have witnessed surgeons with no ICU privileges change our vent settings on patients. And that's just the minor example.

The MICU is not much safer. 20% of critical care knowledge covers 80% of MICU patients.

 

[deleted171991]

So what is the future role of physicians, in your opinion? Mid-levels are taking over clinical duties in ALL specialties. It's only a matter of time when greedy, old surgeons train mid-levels to do basic operations (already happening at my institution). How hard is it to do orthopedic carpentry or urologic plumbing? Ivory tower centers would LOVE the extra $$$ from training Certified Registered Nurse Operators with DNP degrees.

The future role of physicians is to (mostly) go extinct.

 

[MSmentor018]

I also think this could more rapidly get out of hand - the CRNA issue is out there and state/national societies are doing a reasonable job at keeping things controlled for now (and have for a while).

I don't know if there is any national/state societies actively working against the issue presented here, certainly not in an effective way. This has the potential to get out of hand Quickly as FFP alluded to. PAs will join the howl soon enough as well, adding another layer to the problem (especially if they adopt the new moniker "Physician Associate" which is almost laughable).

anesthesia almost lost total control but gained some of it back, partly in the political realm and the advent of the AA. nice job.

from a medicine standpoint the layer for the app (advanced practice provider) is already here. they now have their own DEA license/unrestricted rx privileges. no longer can I deny inappropriate rx or tons of xanax/soma/percosnacks they write for b/c by the time I see the chart, the pt is done and gone. PA's are definitely not being outdone by the ARNP crowd. Popping up all over are "fellowships" and "doctor-like" degrees that allow PA's with 3 yrs exp to do classroom work for 2 yrs in hopes to get them equivocal to our training practices, earning a DSc, PhD, DHSc, DrPH, EdD and now using the title "doctor X" in clinical practice. everybody wants the title but doesn't want to put the time, sweat and effort in. in emergency medicine it's like the vietnam war, the combination of politics, corruption, our own self egos, we lost.

 

[Ttan]

I'm interested in going into critical care, but if any of you have seen my previous posts on this forum, I don't like working night shifts.

This guy alludes to the health effects of doing shift work and nights. Do these eICU programs provide 24 hour coverage to hospitals? Or do they mainly provide night coverage, leaving day coverage to in house intensivists? Potential to free up night shifts, or is it just going to take all the jobs, day and night?

 

[deleted171991]

I'm interested in going into critical care, but if any of you have seen my previous posts on this forum, I don't like working night shifts.

This guy alludes to the health effects of doing shift work and nights. Do these eICU programs provide 24 hour coverage to hospitals? Or do they mainly provide night coverage, leaving day coverage to in house intensivists? Potential to free up night shifts, or is it just going to take all the jobs, day and night?

If you hate working nights, my advice is to stay away from critical care. Sooner or later, if not already, eICU centers will provide 24 hour-coverage, at least for the smaller hospitals with no board-certified intensivists on site.

What Emory did with sending their night team to Australia is unique, AFAIK, and visionary. I doubt that it will become the norm soon. Plus bigger hospitals will still want an in-house intensivist at night.

Our problem in intensive care is poor scheduling. That will not go away soon either. There are many solutions to having a more rested and happier workforce, it's just that most employers don't give a crap. Meditation sessions, stress relief training and other bs, for people who just need more natural sleep during the night and fewer hours at work. The Europeans are onto something.

 

[eimaise]

The future role of physicians is to (mostly) go extinct.

Man this thread is really depressing. Please tell me some good news as someone planning on applying to CCM next cycle.

 

[deleted171991]

Man this thread is really depressing. Please tell me some good news as someone planning on applying to CCM next cycle.

The good news is that it will probably take many years before it becomes bad. Right now, there is still a high demand for medical intensivists.

 

[AdmiralChz]

Man this thread is really depressing. Please tell me some good news as someone planning on applying to CCM next cycle.

Still plenty of intensivist openings nationally (even Anesthesia CCM, but mostly academics). And still time to stem the tide and assert yourself as in charge of the ICU - when you see such behavior, stamp it out.

 

[DubbiDoctor]

The future role of physicians is to (mostly) go extinct.

Can't see any scenario where hospitals could replace neurosurgeons and CT surgeons with midlevels. Really any sufficiently long integrated training pathway is closed off to midlevels, as they exist for abbreviated training. Physicians who do 3-4 year residencies or practice in a subspeciality using mostly their subspeciality training will likely become most replaceable as midlevel providers continue to be pumped out. The problem for most doctors is that for the most part they don't need the level of training they receive for most of what they do. To save money, the mid-level provider was established to do low-acuity care, freeing up physicians to focus on high acuity care. But there won't be enough demand for physician-only care to provide lucrative jobs to all physicians. That is, the physician to population ratio isn't declining in tandem with the increase in the midlevel to population ratio. So most physicians will become increasingly replaceable by mid-levels.

 

[MEN2C]

From what I've seen - places are actually going the other way, and having intensivists stay in house overnight...

 

[MEN2C]

I don't think you guys should worry. There is a whole specific specialty certification for Neonatology for NPs (NNP) and they aren't replacing neonatologists. I suspect the same will happen in the adult world.