What is the midlevel situation in CC?

[MEN2C]

Depends where you work. In a set up with NNP/Neos, the Neos are usually the backup airways for example. But at some of the places I've rotated at, they prefer to do it themselves. In a larger unit, you are generally in a supervisory role (with some exceptions). In a smaller unit, there are solo jobs where you do everything yourself. The main job of a neo is to run rounds, come up with plans for the day, and be there when SHTF.

I'm not even a fellow and I'm already tired of stuff like LPs, so I for one am happy to delegate that stuff.

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[AdmiralChz]

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.

The peds world (especially neonatal!) is very, very different from the adult world. That being said, in residency at night the NICU was essentially run by an NNP and residents under him/her. I Know nothing about the workings of such units, which is why my comments above apply mostly to SICUs.

 

[CCM-MD]

Recent sentinel event relating to something missed by a NP caused a nearby hospital to move to add physical night time intensivist presence. This is a hospital near me with ~30 ICU beds with 2 day time intensivists - previously had cross-coverage with midlevels at night and hospitalists admitting to the ICU at night. They just added a night time intensivist.

 

[deleted171991]

Recent sentinel event relating to something missed by a NP caused a nearby hospital to move to add physical night time intensivist presence. This is a hospital near me with ~30 ICU beds with 2 day time intensivists - previously had cross-coverage with midlevels at night and hospitalists admitting to the ICU at night. They just added a night time intensivist.

Awesome. Just the lifestyle everybody is looking forward to.

 

[CCM-MD]

Awesome. Just the lifestyle everybody is looking forward to.

This specialty is not for everyone. Not sure whats worse - home call or staying in house. Both have their own problems. If the acuity is on the lower side I'd probably go with home call than having to be in house at night. But slightly higher acuity and home call can turn into a nightmare and ruin your entire week.

Interestingly, I have run into several people who prefer working nights. There can be a nice compensation differential.

 

[MEN2C]

Awesome. Just the lifestyle everybody is looking forward to.

Can't really have it both ways. If we argue that these sick and complicated patients require BE/BC attending level care, then we have to be there. I think the encroachment that people are complaining about in this thread occurs when people try to have it both ways.

 

[chocomorsel]

Depends where you work. In a set up with NNP/Neos, the Neos are usually the backup airways for example. But at some of the places I've rotated at, they prefer to do it themselves. In a larger unit, you are generally in a supervisory role (with some exceptions). In a smaller unit, there are solo jobs where you do everything yourself. The main job of a neo is to run rounds, come up with plans for the day, and be there when SHTF.

I'm not even a fellow and I'm already tired of stuff like LPs, so I for one am happy to delegate that stuff.

And this is where we hang ourselves. We give away procedures when we are tired of them or are lazy and delegate to the nurses, creating a slippery slope.

It’s your job, just do it. You give nurses an inch they want a mile. We gotta lose this attitude of delegating stuff to nurses. We are creating our replacements.

When I am in the OR and have to put in a line, I do it even when I don’t want to. I don’t go looking for a nurse to do it for me.

When I get called to do an LP on a patient I don’t want because I am tired, I do it. It’s part of my job. When I have to do a blood patch for a problem I did not create, I don’t go look for a CRNA to do it. It’s part of my job, so I do it. Get it?

Stop all this bull**** “delegating”. It creates problems and gives the nurses the idea that “I don’t need a physicician, I can do it all.”

And yes, I know procedures don’t a physician make. But that’s where this s hit starts.

 

[psychbender]

I was at SOCCA this weekend, and heard a speaker from NY talk about midlevels in the ICU, setting up appropriate staffing, etc. He was talking about empowering your APPs, and ensuring that, when PA that places all of the lines teaches the resident, that they're learning from the best. Also, that when he eventually needs to be in the ICU, he wants the PA that does twelve a day to put in his central line. I'm just sitting there, floored, thinking, "What the ever loving **** is wrong with you?!" The residents should be learning from YOU how to put in lines. YOU are supposed to be the best in the hospital at performing and teaching this skill. Also, where the hell are you working that you have a PA that puts in 12 central lines a day in the ICU? Shouldn't some of those be going to your residents or, heaven forbid, the attending or fellow to do? Lazy ****ing people in academics and private practice are ruining medicine by thinking that they are above the tasks that they were trained and hired to perform.

 

[CCM-MD]

I was at SOCCA this weekend, and heard a speaker from NY talk about midlevels in the ICU, setting up appropriate staffing, etc. He was talking about empowering your APPs, and ensuring that, when PA that places all of the lines teaches the resident, that they're learning from the best. Also, that when he eventually needs to be in the ICU, he wants the PA that does twelve a day to put in his central line. I'm just sitting there, floored, thinking, "What the ever loving **** is wrong with you?!" The residents should be learning from YOU how to put in lines. YOU are supposed to be the best in the hospital at performing and teaching this skill. Also, where the hell are you working that you have a PA that puts in 12 central lines a day in the ICU? Shouldn't some of those be going to your residents or, heaven forbid, the attending or fellow to do? Lazy ****ing people in academics and private practice are ruining medicine by thinking that they are above the tasks that they were trained and hired to perform.

I could probably teach an intelligent monkey how to do a central line. Probably impossible teach it how to manage most ICU patients. If my PA does a line and allows me to see an extra patient, I think thats a win.

 

[deleted171991]

You are both right.

I rarely put in lines (I find them boring), but I am always in the immediate vicinity to watch and help if needed. But almost no midlevels should be teaching/supervising residents, not even a line.

 

[chocomorsel]

This specialty is not for everyone. Not sure whats worse - home call or staying in house. Both have their own problems. If the acuity is on the lower side I'd probably go with home call than having to be in house at night. But slightly higher acuity and home call can turn into a nightmare and ruin your entire week.

Interestingly, I have run into several people who prefer working nights. There can be a nice compensation differential.

I like nights myself. Less B.S to deal with

 

[deleted171991]

I like nights myself. Less B.S to deal with

I used to like them too, in fellowship (high acuity place, many patients). As an attending in a smaller much lower acuity setting, I enjoy having continuity a lot, and I would be pissed if the night person f-ed up my plan of care. I can tell an in-house midlevel or resident what (not) to do (and to call me), but I couldn't micromanage an attending.

 

[CCM-MD]

I would work nights permanently if I didn't have a family.

 

[857937]

I would work nights permanently if I didn't have a family.

Do you get used to it?

I'm still a resident who loves nights also but the idea of signing a nocturnist contract in the future and being miserable or having to resign from the job scares me.

How do I make sure nights are for me?

 

[CCM-MD]

Do you get used to it?

I'm still a resident who loves nights also but the idea of signing a nocturnist contract in the future and being miserable or having to resign from the job scares me.

How do I make sure nights are for me?

Only way to know for sure is by trying it out. Depends heavily on the set up. How good are the bedside nurses? Are verbal orders acceptable? Are you being called about every little thing? How many patient encounters in a typical night? What is the acuity of patients? How good is the ED - are you being consulted for “hey man I got a sick one, probably doesn’t need the unit but he’s a sickie, can you take a look at him”? Are you responsible for non-ICU codes? Do you have residents or midlevels to do chart review and H&Ps, allowing you to focus on management?

Lots of variables. Like any job there are good gigs and bad gigs. Right out of training people are willing to do pretty much anything that pays but become more selective with time.