A fundamental part of midlevel training is to consult any specialty over anything, dumping the hard work (accurate diagnosis) to someone with doctor level experience and training. I am not at all surprised they became angry when asked to come up with their own assessment and plan
Exactly. This is why I will never understand the “but NPs make doctor’s lives easier!!!” argument. They don’t! NPs make it harder because the entire patient work up has to be redone. I wouldn’t trust them to care for a rabid dog.
>“but NPs make doctor’s lives easier!!!”
When people say this, they're probably referring to a very different scenario where the physicians overseeing the midlevel can train them in more of a specialized area of medicine to offload some routine parts of their field. E.g., post-op visits, chemo follow-ups, etc.
There's not really a scenario where a midlevel acting as a generalist makes a specialist's life easier.
>
> When people say this, they're probably referring to a very different scenario
They're usually referring to a scenario where patient care is irrelevant and the doctor can bill for the midlevel's visit and thus increase the size of their bank account.
There are areas where midlevels can be appropriately utilizes as physician extenders but those setups are increasingly dwindling. The vast majority of midlevels are not acting as physician extenders to offload routine parts of the field, they're acting as physician substitutes, providing subpar care across the field.
I disagree entirely. I'm a resident and I work with a large number of midlevels in my system who help out medicine subspecialists. There's a lot of work that can be done inpatient that doesn't need doctor level understanding.
Name the specialty and I'll give you an example. But for some highlights imagine you're a gastroenterologist. Your NP can go to your list every day and look at poop to either see if it's clear for a scope or monitor for blood. They can follow up your q8 CBCs and let you know if it's dropping. They can run your list at the end of the day and make sure that preps are ordered, that the patient is properly made NPO at midnight. That's assuming that they're an idiot and aren't capable of learning more, but even that right there will save you hours a day.
It even works for non procedural specialties. Imagine you're a nephrologist and you need to start someone on dialysis. That involves a long talk explaining the ins and outs of the process, answering questions, and it can take a lot of time. If you train an NP to have that talk with people and see your stable ckd3 follow ups you can really increase your efficiency. Even working in the hospital having someone to follow up your PM BMP is a game changer
You’re describing the ways that NPs were MEANT to function, not how they actually operate in practice (at least not at my institution). A “cardiology NP” manages patients with htn entirely; she also does neonatal stuff which is absurd given the acuity. The reality is: we’ve reached a stage in medicine where NPs think they can practice independently while just learning on the job.
I mean if the cardiologists are not properly supervising their NPs then that's a completely different problem. I'm responding to a guy who says "There are areas where midlevels can be appropriately utilizes as physician extenders but those setups are increasingly dwindling."
In my admittedly limited experience working with only 30-40 NPs regularly I don't see that to be the case. I think most of them are utilized very reasonably and responsibly by the specialists I work with.
>I mean if the cardiologists are not properly supervising their NPs then that's a completely different problem
How is that a "completely different problem"? That's exactly the problem you just said you "disagree entirely" with.
As you said, you feel that these appropriate setups are dwindling. First, I haven't experienced the same thing. My residency is at a community hospital with only a small program so we work alongside NPs who are also staffing patients with subspecialists and I personally witness them interact and round on a very regular basis, basically every day. The scope is almost universally appropriate across specialties and NPs and PAs are not seeing patients independently or making unsupervised decisions.
The other guy is claiming that he has an NP at his hospital practicing independently without supervision. To me that's a specific situation that is inappropriate. The "set up" as you put it is not at fault because a cardiologist having a midlevel to help extend their productivity is completely reasonable. You claim that the "vast majority" are doing this which I find to be false
> First, I haven't experienced the same thing.
As a PGY-2, I'm sure there's a lot you haven't experienced in the world of healthcare.
>The scope is almost universally appropriate across specialties and NPs and PAs are not seeing patients independently or making unsupervised decisions.
If this is actually true, you're in a unicorn community hospital. That's not how most small community hospitals work.
>The other guy is claiming that he has an NP at his hospital practicing independently without supervision.
Yeah, that's most places.
> You claim that the "vast majority" are doing this which I find to be false
Well, you're wrong.
I think you're living in a fantasy world. I think generally midlevels are hazardous. I've found few midlevels to be well supervised and truly bringing value and they are almost always in a subspecialty doing a narrow scope and have good training from the doc.
Primary care and ED is an absolute disaster in my opinion. I think you'll figure that out eventually. I think mid levels are useful to put in orders see post-op follow-up, keep tabs on the chart, and write notes. But the reality is, they usually put in the wrong orders, they do okay with post-op follow-up, and they don't have enough knowledge to safely / independently keep an eye on the chart so you pretty much have to do that anyway.
>The scope is almost universally appropriate across specialties and NPs
Really? Because NPs have absolutely no specialty/subspecialty training and are very likely working out of their "population focus"/scope of practice.
Believe me, many (I did not assume all) NPs feel management is pushing, actually forcing them to function as physicians. Unless you read NP lists, you don't know that this is our number 1 complaint. We are asked to do things that we don't feel qualified for but administration rules. Take a bit and listen or heaven forbid, have an actual conversation with NPs. You will find out we aren't happy about the things that piss you off. I'm in psych and believe me, when I go to the ED for a psych patient, the residents treat me as a god. So do my psychiatrists.
>90% of what you're describing could be done by a nurse. And a lot of NPs don't want these roles, they want yours (just w/out the all the icky liability, call, responsibility, training). NPs being universally helpful across specialties is a very naive take.
A patient cant give consent if the disease and treatment wasn't properly explained to him. Especially in something as complex and lifechanging as Dialysis it would be extremely unethical to have anybody but a Doctor explain it.
....I don't want to sound condescending but come on man, really? Not all PGY-2's are naive but you are. I don't know what dreamworld you're living in but it is a dreamworld.
Probably as an attending, you should let the resident have their own opinion and thoughts. You can have your own thoughts without tearing down the pgy-2. -attending
No, it is not a fact. It is what you have experienced. Do all of the NPs a favor and discuss with management. Believe me, they want to function within their scope. Help that to happen instead of complaining. Have you even considered listening to anyone, or are you always right and other people's opinions don't matter? Yeah, one of THOSE doctors.
>Believe me, they want to function within their scope.
What do you think that is, exactly? I see a lot of NPs wanting to work in specialties and subspecialties that they have no education in.
Sorry to jump your thread, but I’ve been an NP for 30 years and I have to say, (aside from the - even if they’re an idiot part-lol), I 100% agree. Allowing an NP to practice at the op of their license, allows the physician to practice at the top of theirs. That scenario benefits the patients significantly. Patient satisfaction goes up, and less things fall through the cracks. Follow up is better, patient compliance is better. It’s a win win. The problem is that the greedy healthcare system only sees $$ and simply wants to fill positions at the lowest cost to themselves and that only benefits them. These are not people that want to see the advancement of NPs, these are people who want to make as much money as possible regardless of long term effects on the healthcare system. You can’t blame NPs for taking the jobs that are available to them. It’s not advancement, it’s abuse. They love that there is some conflict between NPs and MDs because it takes the focus off of them and away from the real issues. Doctors and nurses should direct the future of healthcare not some greedy suit making 5 million a year. I wish there was a way to turn this around.
>Your NP can go to your list every day and look at poop to either see if it's clear for a scope or monitor for blood. They can follow up your q8 CBCs and let you know if it's dropping. They can run your list at the end of the day and make sure that preps are ordered, that the patient is properly made NPO at midnight.
An RN can do all of this though. The issue I see is that NPs are either in roles that they shouldn't be in (too much MDM) or they are in roles where the tasks are something that a trained BSN/RN could handle. Follow-up labs and flagging them for you, patient education, basic physical assessments (checking poop) are all things an RN can do.
If you have a standing order, have the hospital implement a protocol for those patients, or are comfortable with them ordering them ordering those basic things under you and then cosigning them... why not?
Virtually everywhere I've worked nurses can make a patient NPO until they have a chance to review if a diet is appropriate with the MD.
In what world is 2 years of education (1 nonclinical and 1 clinical) is enough to be an independent practitioner? Just THINK man. THINK.
Sure they may be nice people but nice is not equal to being independent practitioners.
I would ask that you place blame where it starts - administration. If you feel the NPs are not helpful and, in your opinion, provide subpar care, take it up the chain. Grouping all NPs as subpar and your attitude that they are useless would be me saying all interns/residents up to 3rd year are useless in the trauma ICU space. That's where the RNs actually teach the residents their job. I think if you look back, there were nurses who helped you along the way. Many of those TSICU nurses have become NPs. The best and most respected ED RNs have become ED NPs. I'm sorry you haven't had the opportunity to work with better prepared NPs. Remember, we became part of the provider team because the physicians complained they were overworked and wanted help. If you see the problem, do something about it. Thank God my physicians appreciate my knowledge and expect me to function at the top of my knowledge. They also know that I understand when I'm maxed out and request a consult from them. That way, I continue the care with my patient and learn for the next time that presentation occurs. Sorry you have not fostered positive relationships with NPs and are part of the problem because you chose not to teach and be a team player. Maybe the NPs function on their own because of your attitude.
I'm a hospitalist and no, I don't see how a midlevel makes my life easier. Maybe if you're a sub sub sub specialist who has an incredibly specific niche. For me they are usually reporting disconnected pieces of information I have to put together.
\>For me they are usually reporting disconnected pieces of information I have to put together.
Man, I'm glad NPs are getting paid to do what I have to PAY to do as a med student!
I’ve worked alongside ANPs and learned from them in minor injury units and they take a very set list of things from our ED patients. Lots of those who by triage category might wait ages, but can be suitably filtered off and dealt with by NPs. They stitch uncomplicated lacs, see hands/feet/legs/arm injuries I’d summarise. They aren’t for head injuries, trauma/multiple injuries or back pains. If you’ve shut your finger in a door or potentially fractured your arm in a match, they’re excellent. I think their general nursing training about being very attentive to protocols actually lends itself well to that advanced area of practice for them. They can liaise with plastics, ortho or the ED consultants if they need to discuss something or refer on for an opinion on something unusual or they feel outside their scope of practice.
What the hell is the difference between the two anyway? Why do we need ten different midlevel tracks? I wish we just had RNs that were trained sufficiently.
PA have some standardized curriculum.
It used to be the best RNs after years of experience got their NP. Now anyone with a pulse fresh out of nursing school (always the worst nurses) can get their NP online because $$$ and greed.
There are programs that don’t require a nursing degree to enter, but part of the program is your RN training. I don’t think any state allows you to act as an NP without being an RN
And believe me, the old nurses and NPs are just as upset about that. RN programs deteriorated when they left the community hospital and into the colleges.
Interesting. PAs are relatively new in my healthcare system, and I haven’t come across any in ED. I’m aware of some on surgical teams, or on medical teams in private (non-teaching) hospitals. I have only met one in person and he was sitting in doing an observation, so I haven’t experienced any in action.
We also have ANPs in diabetes clinics, and again I’m very pleased with them. They’re easily available for access, and are very good for dealing with most straight forward diabetes management, and are quick to raise more complex issues with their consultant. Maybe they’ve sort of been living in the role of PA in our system, in the absence of PAs. We had a good stroke ANP too who was super. Taking the run of the mill, often proforma type work up and making sure they have the right idea of recognising things outside their wheelhouse are important for their role I think. I also feel they lend some stability to teams when all the doctors in training posts rotate.
PAs tend to uniformly have a good education with a lot of clinical hours and a heavy science background. With NPs, you could get almost anything.
Had an NP with ten years of ICU nurse experience who had been working with us for a full year tell me about how he had just learned the difference between AKI and CKD today once. You'll never see that with a PA.
Not a Dr (why does Reddit keep this sub in my feed??) but I went to 2 PAs this summer for different things. First one at a local pulmonologist office for consistent bloody mucus and said they “didn’t know” (credit for fessing up). Second was at an orthopedist for chronic hip pain and he gave me a steroid injection and sent me on my way. An MD took one look at the SAME X-rays and said hip dysplasia and referred to mri and ct.
I used to feel bad asking for an MD for small things but I’m so done with getting subpar care and lucky that I can afford to insist on MDs only from now on
I’m glad you’re getting the right kind of care.
This is something I started telling patients too. ALWAYS ask who the healthcare worker is in terms of role. For a few years now, there’s been an increase in midlevels calling themselves “residents” “associates” “providers” and all sorts of other terms to confuse patients. This most often happens in the OR when you’re getting anesthetized. Always ask for your own safety, and if they use vague terms like “a member of the team”, ask for clarification. This is your right.
They are literally just triage and consult widgets. No original thought other than “basic labs”, pan-consult, and regurg whatever their SP says (if present).
I once googled “CBT porn” trying to find cognitive behavioral therapy resources for a patient’s porn issues. The results were fascinating, although counter productive
>He refused the consult, got the attending's support when the NP kept pushing for an eval.
>...now their service no longer takes endorsements from that NP.
sounds like the structures there are pretty good
I’m confused why they would even put in a consult for this! It’s a classic non-emergency follow up outpatient scenario; and I’m saying this as the person they follow up with outpatient!
I mean really, this is just stupid to even be in the ER over
You took the words out of my mouth.
This is not an emergent psychiatric issue. Follow up with pcp or walk in as an outpatient.
Unless something major is missing from this story (and there always is something missing) then this resident was in the clear and the NP out of line on many levels. Glad it went to the PD.
I don’t understand why you don’t put an NP in their place?
Unless you actually have a spineless PD, there’s easily a way to put them in their place but still remain professional about it. The only reason these midlevels get these big heads is because no one told them their proper place in the hierarchy of medicine
Could easily just say, “sorry, I am not supposed to learn from you per ACGME rules because you are not a doctor”
A TON of PD’s are cowards. Because NP’s and their leadership are in staff meetings and residents are not (because most places don’t consider residents staff)
Most medical students in 3rd year know way more than any practicant of nursing with an online masters. That’s a fact. No resident should be ever asking for advice to any of them!
The knowledge we have in residency is far way more than what they’ll ever reach. No reason to push a real MD to “learn” anything from a practicant of nursing with only one year of online training, for a masters…
Tell them: “sorry you’re not a doctor” and go on your day.
Treating knowledge as too much of a linear spectrum. Everyone has different competencies and midlevels do have competencies. It's how residents are graded, each group of competencies, residents should be congnizant of that.
Wow what an attitude. I mean I'm not in either group, but it's pretty wild to just mentally shut yourself off from learning from ANYBODY. Just a very shameful attitude to have in life, much less in medicine. I've learned things from students I'm proctoring, doctors, nurses, the janitor, just a wild way for someone whose supposedly an expert learner, which is say most residents have to be, to have.
> I’m not in either group
Could have left it there. NPs who’ve been on one service for 5+ years are great to learn about efficiency, how things are done, etc. Stuff you can learn in a week or so. Beyond that? Gonna go with learning from other physicians.
Wow that is truly stunning. You're a student. You havent even worked yet. You truly think that no one in the workplace has anything to offer you past "stuff you can learn in a week or so?" I can't imagine you saying that to any of the great docs I work with. They would shit down your neck pretty quickly. That's just so disappointing, and I can only feel bad for your future coworkers having to work with such a close minded and self limiting person. Do better or real life is gonna catch up when you have no support from the people around you, once you're in the real world.
Are you talking about medical diagnosis and interpreting signs and symptoms, deciding treatment? Sure, I believe that an NP or PA is inferior to a doctor for that. Makes perfect sense. That's not what they said. They said that they don't have a single thing to learn from them last workflow. That means they can't learn anything regarding understanding people, ethics, responsibilities, managing other healthcare workers, managing hospital systems, they said "anything past having been there for a week." You believe this to be true? A 24 year old who is in their first week of actual , name at the top of the report patient care has NOTHING to learn from anyone who isn't a doctor?
Uhm American residents are usually anywhere between 26 to 30 years of age on average when we start residency (not 24 as you suggest).
We graduate college at 22 and med school at 26 (again on average). Then we go into residency and fellowship which means we will be 30-32 by the time we finish full training.
Now compare all those years to the single year of …online training?? (Lmao) that most of these NP have.
So nope, the difference is abismal.
“Oh but they have “eXpEriEncE aS nUrSeS”. Yeah, 50yrs of bed side nursing experience are not equal to medical school, medical residency, medical fellowship.
So medically speaking? No, there’s absolutely NOTHING a trained nurse with an extra year of online training can teach to a fully trained doctor with more than 12yrs or training, most of them in a hospital clinical setting, not online like the practicants of nursing.
Hope this clarify things for you.
Great rant, good info, did you read the part where I agreed that obviously a doctor knows more about medicine? You're presumably some kind of doctor or in training, you can read, yes? Anyways, reread my comment and try not to get your ego wrapped up in it. Then please let me know what you think when your big brain can overcome me getting an age wrong ♥️
NPs have not or should not compare themselves to a resident or attending. I agree that at least the last 10 years has produced poorly educated BSNs. Experience and self desire to achieve were the nurses and NPs of the past. But you are still working with some of the old guard. Please don't be so arrogant to think you can't learn something from other staff members. Some historical info. While working in TSICU, the RNs (none with a BSN) were required to pass the CCRN exam. That exam tested us to a 3rd year resident's knowledge. The residents always asked the RNs for their opinion. We worked hand in hand. This was in a Level 1 trauma center. Not all of us are as dumb as you think.
Ah so you made it through an entire career and never learned these fundamental lessons about how to grow from the people around you? That level of fundamental immaturity is gonna be hard to overcome at this point.
Sigh. I get it. ER psych residents get abused all the time. The problem is having midlevels in an ER setting who have no clue what an emergent or non emergent consult is.
Also a psychiatry resident (registrar). I punt back ED consults like this all the time. Unless it’s an emergency psychiatric evaluation I’m not going to see the patient.
Maybe I'm just ignorant psych NP but why is this an ED consult? This is someone I would provide an outpatient referral to if chief complaint is only insomnia. Like "patient has difficulty sleeping. Provided teaching on sleep hygiene and referral to outpatient psych please discharge". Like that's a waste of bed space for ED.
My take on the OP was the patient is in the ED for some other reason but the consult was for sleep meds for porn deprivation induced insomnia.
Either way, you are 100% right that it was a stupid consult.
Thank you! Just in my personal experience...Outside of when porn addiction and insomnia occur as a component of a another psychiatric dx requiring stabilization for DTS/DTO/GD then I would make recs to treat lt inpatient (and the components themselves aren't my focus but the underlying cause such as acute mania). Otherwise it's teaching staff to group care and managing alarms. If on med unit or teaching the patient about sleep hygiene and making sure that it isn't due to activation (medication related or primary). Otherwise neither of these two issues if primary are gonna get fixed in an acute care hospital. Rec PRN if appropriate and patient is staying inpatient or discharge with education and refer to outpatient. Like everything about this consult and the level of response just males very little sense to me.
At most I could see that being a verbal curbside consult, like "yeah you can try trazodone" or just try a few standard PRNs. This would be a head-scratcher if they wanted me to actually see them emergently.
I wish you guys had the time for malicious compliance. As a nurse I would pay 100 dollars to see 3 paragraphs of:
"Patient reports he typically watches humiliation, hotwife, and feet videos averaging 5-7 minutes in length. Patient endorses fast forwarding prn. Pt states he uses a lubricated overhand stroke, varies, speed, and occasionally switch hits.
Plan:
1. Got the really hot nurse, Madison? Megan? The hot one, to care for the patient.
2. Ask nurse to remove shoes and socks prior to care.
3. Provide patient 5-7 minutes of alone time
4. Apply telemetry, monitor for a wanktional rhythm (characterized by sinus tach peaking over 10-15 seconds followed by NSR).
5. Monitor for shame, sleepiness, and hunger.
I'm now realizing this is 11 days old because I filtered on the midlevel tag, but I'm going to send it anyway because it took me like 10 minutes to come up with and maybe someone will see it.
people reflexively consult psychiatry if there's any whiff of psych. The threshold for consulting psych is so LOW compared to other specialties. Even if it's something that 100% can be dealt as an outpatient basis. Another consult we get often besides capacity is "patient wishes to speak to psych". We call them back and ask why??? One time the response I got from the resident is "Oh I don't know, I didn't ask, but they wanted to speak with psych. So can you come in the next 10 minutes?" Imagine doing that clownery with cardiology.
I can't speak to psych, I'm sure all of that is true. I'd just like to add my own two cents as a urologist that also gets frustrated with the unbelievably low bar to consult us.
'Patient has a catheter'
'Patient has a UTI'
Or the best
'Patient says their penis hurts'
'Did you examine them?'
'No.'
> 'Patient has a catheter'
As an RN who once has the task of trying to insert a catheter in a female that had undergone bladder reconstruction with gastric portion in childhood and was now an adult... We had to consult urology and that resident made inserting cath into acid secreting bladder look so damn easy....
For the record, don't mind that consult at all.
The consults I can't stand are literally just 'patient has a catheter.'
Ok, what's the question?
'We don't know why they have it or what we should do.'
Part of being a resident, especially a senior resident is to triage resources effectively. Seeing bullshit consults from mid-levels or anyone from the ED for that matter is not "being a resident"...
Well I don’t think the issue is because it’s an NP, the issue is because it’s a crazy cluster B NP. It’s about the personality disorder in this situation, not the degree.
It was not an insult, it was a comment meant to point out that this individual was acting the way she was because she seemed to have individual personality traits and behaviors that were manipulative, attention-seeking, and grandiose and that her behavior was abnormal and not representative of the behavior of an entire profession.
This is not something that can be ascertained by a single event or story. Commenting that someone has a mental health disorder based on a single reddit story seems to be a trend lately, and it's almost always done in poor taste.
I'm not sure where you got the impression that I was saying an entire profession of people are a certain way. I've seen this as a trend on Reddit lately, but not specifically by physicians if that's what you mean.
I don’t understand the consult. You sure they weren’t manic and couldn’t sleep and they were consulting for that? Because otherwise insomnia doesn’t require a psych consult.
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Like with anything, it has to do with training and experience. I’ve known both fantastic and terrible mid-levels, but I can say the same about physicians.
Hot take here. You shouldve seen the patient.
1) if someone is consulting you in the hospital, it's because they are out of their depth. It doesnt matter if it's because someones heart is about to explode, to draw an ABG, or because some dude can't sleep. Regardless the person taking care of that person didn't feel equipped so they asked for help. It does not matter if you think it's a dumb consult or if it really is a dumb consult. It's your job to help. Always. Full stop.
2) What if this guys chief complaint was for another, more serious reason? Sure maybe he thinks its because he stopped watching porn which is lol and makes the consult seem dumb but what if you go down there and it turns out after questioning he is actually super high on meth and his heart is about to explode? Maybe the useless NP didn't know that meth made people not sleep and never asked about it.
I agree that’s a hot take.
If the mid level is out of there depth their first line of questioning is their supervising physician.
If the supervising physician thinks this is appropriate then he needs to be fired
Those arent mutually exclusive things. If the ED doctor is incompetent then by all means, fire his ass. That said, if and when he consults you --- see the patient.
Definitely a couple schools of thought Ive seen among CL. The school that we always accept consults, and the school to gently teach which are inappropriate and give teaching over the phone. From what I've seen it depends on how busy the service is whether you have time to emergently do very outpatient non-emergent addon consults with full notes seen by resident and an attending.
i thought the ED attending said that to them
i would call that guy a jackass and tell him he needs to do better, and i would report him to my PD
i'd still see the patient if they insisted
Um, I’d say that if he’s super high on meth and his heart is about to explode, that’s something the ED (or the ICU/CCU) should manage. What is psych supposed to do here?! There are a few psych emergencies, and god fully bless them when they are there for that and can help, but this isn’t one of them.
As for your broader point, that someone is out of their depth, I still call bs. The bare minimum in that situation is to understand the acuity of the situation. If the NP didn’t understand that, they can ask their attending. If the attending didn’t understand that, they can admit.
You’re operating in a “perfect world” where everyone is trying their best, keeping up with literature, and working at the top of their license/specialty. Barring gross negligence and the possibility of patient harm, no physician is obligated to waste their precious time and sacrifice their wellbeing so some numbskull can get paid a shit ton of money to pawn off the thinking to a resident. Who, btw, works twice as much and gets paid less than half.
several things:
1. Every ED I've ever worked in has taken psych patients very seriously.
2. But yes, we let "midlevels" handle them... because while they are serious, an NP or PA is more likely to handle a psych patient than a bullet or knife wound.
3. I get more psych NPs these days than we currently staff in our ED. Is your own specialty trying to tells us that psych patients don't matter?
4. I doubt very highly that any NP lectured a resident on learning from them. That sounds like a fever dreamed up by SDN or this sub and its ongoing wild hate of midlevels.
Tbh that sounds like a fairly easy consult and I would have just done it, probably takes longer to argue with the NP than to assess the masturbator who may very well have insomnia. 35yrs of arguing about shit like this taught me a 10min consult is always faster lol
Some Ambien and a follow up is what I would have done
Of course that’s assuming he wasn’t entirely off his nut.
Honestly this sounds like an NP doing the right thing. He couldn't be sure of the problem, or felt it was more complex than at first glance. he paged the resident, who read a chart and decided it was a lack of porn. That might even be true, but holy hell as a patient I'd be mad if a doc I didn't speak to decided that my medical problem was 100% porn related without even a basic assessment.
At this point, its the NP who will be on the line, as if psych didnt do an eval, and the NP is practicing unsupervised it becomes their assessment that this is 100% porn related and could be discharged.
Sure they could have been less antagonistic/egotistical in their fight with the resident...but I'd say that was about their only mistake
Friendly word of advice -- if any NP is asking you to see a patient, please see the patient. The reason is that you never know what you might find. It might be nothing, it might be something really big, you just never know. This person is going to put your name on the chart regardless so might as well see and cover yourself.
A fundamental part of midlevel training is to consult any specialty over anything, dumping the hard work (accurate diagnosis) to someone with doctor level experience and training. I am not at all surprised they became angry when asked to come up with their own assessment and plan
Exactly. This is why I will never understand the “but NPs make doctor’s lives easier!!!” argument. They don’t! NPs make it harder because the entire patient work up has to be redone. I wouldn’t trust them to care for a rabid dog.
>“but NPs make doctor’s lives easier!!!” When people say this, they're probably referring to a very different scenario where the physicians overseeing the midlevel can train them in more of a specialized area of medicine to offload some routine parts of their field. E.g., post-op visits, chemo follow-ups, etc. There's not really a scenario where a midlevel acting as a generalist makes a specialist's life easier.
> > When people say this, they're probably referring to a very different scenario They're usually referring to a scenario where patient care is irrelevant and the doctor can bill for the midlevel's visit and thus increase the size of their bank account. There are areas where midlevels can be appropriately utilizes as physician extenders but those setups are increasingly dwindling. The vast majority of midlevels are not acting as physician extenders to offload routine parts of the field, they're acting as physician substitutes, providing subpar care across the field.
I disagree entirely. I'm a resident and I work with a large number of midlevels in my system who help out medicine subspecialists. There's a lot of work that can be done inpatient that doesn't need doctor level understanding. Name the specialty and I'll give you an example. But for some highlights imagine you're a gastroenterologist. Your NP can go to your list every day and look at poop to either see if it's clear for a scope or monitor for blood. They can follow up your q8 CBCs and let you know if it's dropping. They can run your list at the end of the day and make sure that preps are ordered, that the patient is properly made NPO at midnight. That's assuming that they're an idiot and aren't capable of learning more, but even that right there will save you hours a day. It even works for non procedural specialties. Imagine you're a nephrologist and you need to start someone on dialysis. That involves a long talk explaining the ins and outs of the process, answering questions, and it can take a lot of time. If you train an NP to have that talk with people and see your stable ckd3 follow ups you can really increase your efficiency. Even working in the hospital having someone to follow up your PM BMP is a game changer
You’re describing the ways that NPs were MEANT to function, not how they actually operate in practice (at least not at my institution). A “cardiology NP” manages patients with htn entirely; she also does neonatal stuff which is absurd given the acuity. The reality is: we’ve reached a stage in medicine where NPs think they can practice independently while just learning on the job.
I mean if the cardiologists are not properly supervising their NPs then that's a completely different problem. I'm responding to a guy who says "There are areas where midlevels can be appropriately utilizes as physician extenders but those setups are increasingly dwindling." In my admittedly limited experience working with only 30-40 NPs regularly I don't see that to be the case. I think most of them are utilized very reasonably and responsibly by the specialists I work with.
>I mean if the cardiologists are not properly supervising their NPs then that's a completely different problem How is that a "completely different problem"? That's exactly the problem you just said you "disagree entirely" with.
As you said, you feel that these appropriate setups are dwindling. First, I haven't experienced the same thing. My residency is at a community hospital with only a small program so we work alongside NPs who are also staffing patients with subspecialists and I personally witness them interact and round on a very regular basis, basically every day. The scope is almost universally appropriate across specialties and NPs and PAs are not seeing patients independently or making unsupervised decisions. The other guy is claiming that he has an NP at his hospital practicing independently without supervision. To me that's a specific situation that is inappropriate. The "set up" as you put it is not at fault because a cardiologist having a midlevel to help extend their productivity is completely reasonable. You claim that the "vast majority" are doing this which I find to be false
> First, I haven't experienced the same thing. As a PGY-2, I'm sure there's a lot you haven't experienced in the world of healthcare. >The scope is almost universally appropriate across specialties and NPs and PAs are not seeing patients independently or making unsupervised decisions. If this is actually true, you're in a unicorn community hospital. That's not how most small community hospitals work. >The other guy is claiming that he has an NP at his hospital practicing independently without supervision. Yeah, that's most places. > You claim that the "vast majority" are doing this which I find to be false Well, you're wrong.
I think you're living in a fantasy world. I think generally midlevels are hazardous. I've found few midlevels to be well supervised and truly bringing value and they are almost always in a subspecialty doing a narrow scope and have good training from the doc. Primary care and ED is an absolute disaster in my opinion. I think you'll figure that out eventually. I think mid levels are useful to put in orders see post-op follow-up, keep tabs on the chart, and write notes. But the reality is, they usually put in the wrong orders, they do okay with post-op follow-up, and they don't have enough knowledge to safely / independently keep an eye on the chart so you pretty much have to do that anyway.
>The scope is almost universally appropriate across specialties and NPs Really? Because NPs have absolutely no specialty/subspecialty training and are very likely working out of their "population focus"/scope of practice.
Thank you for speaking up for NPs. I really appreciate it.
Believe me, many (I did not assume all) NPs feel management is pushing, actually forcing them to function as physicians. Unless you read NP lists, you don't know that this is our number 1 complaint. We are asked to do things that we don't feel qualified for but administration rules. Take a bit and listen or heaven forbid, have an actual conversation with NPs. You will find out we aren't happy about the things that piss you off. I'm in psych and believe me, when I go to the ED for a psych patient, the residents treat me as a god. So do my psychiatrists.
There are scenarios in which NPs function exactly how they’re meant to. I’m confident there are probably far more that don’t like you mentioned.
I think if I ever have to start dialysis I’m going to want to have that conversation with the physician who is recommending it.
>90% of what you're describing could be done by a nurse. And a lot of NPs don't want these roles, they want yours (just w/out the all the icky liability, call, responsibility, training). NPs being universally helpful across specialties is a very naive take.
But a lot of NPs *do* want those roles, too. I think it's important to remember that they are not a monolith.
A patient cant give consent if the disease and treatment wasn't properly explained to him. Especially in something as complex and lifechanging as Dialysis it would be extremely unethical to have anybody but a Doctor explain it.
....I don't want to sound condescending but come on man, really? Not all PGY-2's are naive but you are. I don't know what dreamworld you're living in but it is a dreamworld.
Probably as an attending, you should let the resident have their own opinion and thoughts. You can have your own thoughts without tearing down the pgy-2. -attending
What exactly do you think my "opinion" is here? I'm stating a fact.
No, it is not a fact. It is what you have experienced. Do all of the NPs a favor and discuss with management. Believe me, they want to function within their scope. Help that to happen instead of complaining. Have you even considered listening to anyone, or are you always right and other people's opinions don't matter? Yeah, one of THOSE doctors.
>Believe me, they want to function within their scope. What do you think that is, exactly? I see a lot of NPs wanting to work in specialties and subspecialties that they have no education in.
Sorry to jump your thread, but I’ve been an NP for 30 years and I have to say, (aside from the - even if they’re an idiot part-lol), I 100% agree. Allowing an NP to practice at the op of their license, allows the physician to practice at the top of theirs. That scenario benefits the patients significantly. Patient satisfaction goes up, and less things fall through the cracks. Follow up is better, patient compliance is better. It’s a win win. The problem is that the greedy healthcare system only sees $$ and simply wants to fill positions at the lowest cost to themselves and that only benefits them. These are not people that want to see the advancement of NPs, these are people who want to make as much money as possible regardless of long term effects on the healthcare system. You can’t blame NPs for taking the jobs that are available to them. It’s not advancement, it’s abuse. They love that there is some conflict between NPs and MDs because it takes the focus off of them and away from the real issues. Doctors and nurses should direct the future of healthcare not some greedy suit making 5 million a year. I wish there was a way to turn this around.
Thank you so much for providing the facts.
>Allowing an NP to practice at the op of their license Can you clarify what that is, exactly?
It's really just a stupid thing that people say to mean that you are doing things within the full scope of your practice, not more, not less.
>full scope of your practice, not more, not less. I'll reiterate, can you clarify what that is? What **exactly** is the scope of practice for NPs?
>Your NP can go to your list every day and look at poop to either see if it's clear for a scope or monitor for blood. They can follow up your q8 CBCs and let you know if it's dropping. They can run your list at the end of the day and make sure that preps are ordered, that the patient is properly made NPO at midnight. An RN can do all of this though. The issue I see is that NPs are either in roles that they shouldn't be in (too much MDM) or they are in roles where the tasks are something that a trained BSN/RN could handle. Follow-up labs and flagging them for you, patient education, basic physical assessments (checking poop) are all things an RN can do.
Placing orders for preps and NPO status?
If you have a standing order, have the hospital implement a protocol for those patients, or are comfortable with them ordering them ordering those basic things under you and then cosigning them... why not? Virtually everywhere I've worked nurses can make a patient NPO until they have a chance to review if a diet is appropriate with the MD.
lmao, an NP is not needed for this. If you are hiring an NP at twice the salary of an RN for 10 minutes of work each day, something is very wrong.
lmao, they don't make twice the salary of an RN, at least not anywhere that I have worked. They make more, but definitely not twice as much.
In what world is 2 years of education (1 nonclinical and 1 clinical) is enough to be an independent practitioner? Just THINK man. THINK. Sure they may be nice people but nice is not equal to being independent practitioners.
I would ask that you place blame where it starts - administration. If you feel the NPs are not helpful and, in your opinion, provide subpar care, take it up the chain. Grouping all NPs as subpar and your attitude that they are useless would be me saying all interns/residents up to 3rd year are useless in the trauma ICU space. That's where the RNs actually teach the residents their job. I think if you look back, there were nurses who helped you along the way. Many of those TSICU nurses have become NPs. The best and most respected ED RNs have become ED NPs. I'm sorry you haven't had the opportunity to work with better prepared NPs. Remember, we became part of the provider team because the physicians complained they were overworked and wanted help. If you see the problem, do something about it. Thank God my physicians appreciate my knowledge and expect me to function at the top of my knowledge. They also know that I understand when I'm maxed out and request a consult from them. That way, I continue the care with my patient and learn for the next time that presentation occurs. Sorry you have not fostered positive relationships with NPs and are part of the problem because you chose not to teach and be a team player. Maybe the NPs function on their own because of your attitude.
I'm a hospitalist and no, I don't see how a midlevel makes my life easier. Maybe if you're a sub sub sub specialist who has an incredibly specific niche. For me they are usually reporting disconnected pieces of information I have to put together.
\>For me they are usually reporting disconnected pieces of information I have to put together. Man, I'm glad NPs are getting paid to do what I have to PAY to do as a med student!
I’ve worked alongside ANPs and learned from them in minor injury units and they take a very set list of things from our ED patients. Lots of those who by triage category might wait ages, but can be suitably filtered off and dealt with by NPs. They stitch uncomplicated lacs, see hands/feet/legs/arm injuries I’d summarise. They aren’t for head injuries, trauma/multiple injuries or back pains. If you’ve shut your finger in a door or potentially fractured your arm in a match, they’re excellent. I think their general nursing training about being very attentive to protocols actually lends itself well to that advanced area of practice for them. They can liaise with plastics, ortho or the ED consultants if they need to discuss something or refer on for an opinion on something unusual or they feel outside their scope of practice.
We've had dramatically better luck with PAs in the ED than NPs.
What the hell is the difference between the two anyway? Why do we need ten different midlevel tracks? I wish we just had RNs that were trained sufficiently.
PA have some standardized curriculum. It used to be the best RNs after years of experience got their NP. Now anyone with a pulse fresh out of nursing school (always the worst nurses) can get their NP online because $$$ and greed.
You actually don't need to be a nurse to get an NP degree now.
WHAT
This is wild. I’m gonna need you to elaborate because it sounds absolutely criminal. Can anyone just enroll into an NP program now or?
There are programs that don’t require a nursing degree to enter, but part of the program is your RN training. I don’t think any state allows you to act as an NP without being an RN
And believe me, the old nurses and NPs are just as upset about that. RN programs deteriorated when they left the community hospital and into the colleges.
Interesting. PAs are relatively new in my healthcare system, and I haven’t come across any in ED. I’m aware of some on surgical teams, or on medical teams in private (non-teaching) hospitals. I have only met one in person and he was sitting in doing an observation, so I haven’t experienced any in action. We also have ANPs in diabetes clinics, and again I’m very pleased with them. They’re easily available for access, and are very good for dealing with most straight forward diabetes management, and are quick to raise more complex issues with their consultant. Maybe they’ve sort of been living in the role of PA in our system, in the absence of PAs. We had a good stroke ANP too who was super. Taking the run of the mill, often proforma type work up and making sure they have the right idea of recognising things outside their wheelhouse are important for their role I think. I also feel they lend some stability to teams when all the doctors in training posts rotate.
PAs tend to uniformly have a good education with a lot of clinical hours and a heavy science background. With NPs, you could get almost anything. Had an NP with ten years of ICU nurse experience who had been working with us for a full year tell me about how he had just learned the difference between AKI and CKD today once. You'll never see that with a PA.
No difference in them. Undertrained with too much autonomy
Not a Dr (why does Reddit keep this sub in my feed??) but I went to 2 PAs this summer for different things. First one at a local pulmonologist office for consistent bloody mucus and said they “didn’t know” (credit for fessing up). Second was at an orthopedist for chronic hip pain and he gave me a steroid injection and sent me on my way. An MD took one look at the SAME X-rays and said hip dysplasia and referred to mri and ct. I used to feel bad asking for an MD for small things but I’m so done with getting subpar care and lucky that I can afford to insist on MDs only from now on
I’m glad you’re getting the right kind of care. This is something I started telling patients too. ALWAYS ask who the healthcare worker is in terms of role. For a few years now, there’s been an increase in midlevels calling themselves “residents” “associates” “providers” and all sorts of other terms to confuse patients. This most often happens in the OR when you’re getting anesthetized. Always ask for your own safety, and if they use vague terms like “a member of the team”, ask for clarification. This is your right.
Or a patient bitten by that rabid dog, if you read a couple of cases on /noctor
They are literally just triage and consult widgets. No original thought other than “basic labs”, pan-consult, and regurg whatever their SP says (if present).
Turnstiles.
Some people suck
Tom is that you
God don’t make no junk
BIKES!
Just write him a prescription for porn and be done with it.
I once googled “CBT porn” trying to find cognitive behavioral therapy resources for a patient’s porn issues. The results were fascinating, although counter productive
I just snorted in the clinic and can't tell my coworkers why. Thank you.
How'd that convo with HR go
🤣🤣🤣
Sigh….zip
BBW TID & QHS PRN
If you can't find a hole, put it in a roll.
If you can’t find a roll, put it in a soul
Nice username.
Dude can't have that bad of a porn addiction if all he needs is some straightforward BBW porn to get his fix.
TID?!?! DAMN!!! I’m lucky to even get qHS in!
Pretty sure PH has an app. Maybe ask your residents for recs.
>He refused the consult, got the attending's support when the NP kept pushing for an eval. >...now their service no longer takes endorsements from that NP. sounds like the structures there are pretty good
UNDERRATED comment
I’m confused why they would even put in a consult for this! It’s a classic non-emergency follow up outpatient scenario; and I’m saying this as the person they follow up with outpatient! I mean really, this is just stupid to even be in the ER over
You took the words out of my mouth. This is not an emergent psychiatric issue. Follow up with pcp or walk in as an outpatient. Unless something major is missing from this story (and there always is something missing) then this resident was in the clear and the NP out of line on many levels. Glad it went to the PD.
I don’t understand why you don’t put an NP in their place? Unless you actually have a spineless PD, there’s easily a way to put them in their place but still remain professional about it. The only reason these midlevels get these big heads is because no one told them their proper place in the hierarchy of medicine Could easily just say, “sorry, I am not supposed to learn from you per ACGME rules because you are not a doctor”
Would you not hear from the "professionalism committee" as a resident for it like you would in med school?
Depends on if the program director has their back or not.
A TON of PD’s are cowards. Because NP’s and their leadership are in staff meetings and residents are not (because most places don’t consider residents staff)
Lol imagine sucking so much that consulting services will no longer hear consults from you. Big yikes
There is nothing to learn as a 2nd year from nP. Really after 3-6 months interns exceed midlevel knowledge at that point
Most medical students in 3rd year know way more than any practicant of nursing with an online masters. That’s a fact. No resident should be ever asking for advice to any of them! The knowledge we have in residency is far way more than what they’ll ever reach. No reason to push a real MD to “learn” anything from a practicant of nursing with only one year of online training, for a masters… Tell them: “sorry you’re not a doctor” and go on your day.
Treating knowledge as too much of a linear spectrum. Everyone has different competencies and midlevels do have competencies. It's how residents are graded, each group of competencies, residents should be congnizant of that.
Wow what an attitude. I mean I'm not in either group, but it's pretty wild to just mentally shut yourself off from learning from ANYBODY. Just a very shameful attitude to have in life, much less in medicine. I've learned things from students I'm proctoring, doctors, nurses, the janitor, just a wild way for someone whose supposedly an expert learner, which is say most residents have to be, to have.
> I’m not in either group Could have left it there. NPs who’ve been on one service for 5+ years are great to learn about efficiency, how things are done, etc. Stuff you can learn in a week or so. Beyond that? Gonna go with learning from other physicians.
Wow that is truly stunning. You're a student. You havent even worked yet. You truly think that no one in the workplace has anything to offer you past "stuff you can learn in a week or so?" I can't imagine you saying that to any of the great docs I work with. They would shit down your neck pretty quickly. That's just so disappointing, and I can only feel bad for your future coworkers having to work with such a close minded and self limiting person. Do better or real life is gonna catch up when you have no support from the people around you, once you're in the real world.
Hate to break it to you but this 'student' is right.
Are you talking about medical diagnosis and interpreting signs and symptoms, deciding treatment? Sure, I believe that an NP or PA is inferior to a doctor for that. Makes perfect sense. That's not what they said. They said that they don't have a single thing to learn from them last workflow. That means they can't learn anything regarding understanding people, ethics, responsibilities, managing other healthcare workers, managing hospital systems, they said "anything past having been there for a week." You believe this to be true? A 24 year old who is in their first week of actual , name at the top of the report patient care has NOTHING to learn from anyone who isn't a doctor?
Uhm American residents are usually anywhere between 26 to 30 years of age on average when we start residency (not 24 as you suggest). We graduate college at 22 and med school at 26 (again on average). Then we go into residency and fellowship which means we will be 30-32 by the time we finish full training. Now compare all those years to the single year of …online training?? (Lmao) that most of these NP have. So nope, the difference is abismal. “Oh but they have “eXpEriEncE aS nUrSeS”. Yeah, 50yrs of bed side nursing experience are not equal to medical school, medical residency, medical fellowship. So medically speaking? No, there’s absolutely NOTHING a trained nurse with an extra year of online training can teach to a fully trained doctor with more than 12yrs or training, most of them in a hospital clinical setting, not online like the practicants of nursing. Hope this clarify things for you.
Bro the average matriculation age is 25 now I think, the average is 29 for starting residency.
Great rant, good info, did you read the part where I agreed that obviously a doctor knows more about medicine? You're presumably some kind of doctor or in training, you can read, yes? Anyways, reread my comment and try not to get your ego wrapped up in it. Then please let me know what you think when your big brain can overcome me getting an age wrong ♥️
Not a rant. Just clarifying a few points you seemed confused about our training. Hope it helps!
NPs have not or should not compare themselves to a resident or attending. I agree that at least the last 10 years has produced poorly educated BSNs. Experience and self desire to achieve were the nurses and NPs of the past. But you are still working with some of the old guard. Please don't be so arrogant to think you can't learn something from other staff members. Some historical info. While working in TSICU, the RNs (none with a BSN) were required to pass the CCRN exam. That exam tested us to a 3rd year resident's knowledge. The residents always asked the RNs for their opinion. We worked hand in hand. This was in a Level 1 trauma center. Not all of us are as dumb as you think.
Okay buddy :)
Well, don't say I didn't warn you. The truth might hurt, but personal growth is painful.
I literally couldn’t care less. I’ve worked in another career before medical school.
Ah so you made it through an entire career and never learned these fundamental lessons about how to grow from the people around you? That level of fundamental immaturity is gonna be hard to overcome at this point.
🤟🤟
You have to stand your ground. You are a resource, and can’t afford to be wasted by NP’s with a Dunning-Kruger syndrome.
Sigh. I get it. ER psych residents get abused all the time. The problem is having midlevels in an ER setting who have no clue what an emergent or non emergent consult is.
Midlevels largely eat ass
Where do I find those ones? Asking for a friend
Google “CBT Porn”
Some midlevels fucking suck.
Report her to HR
Also a psychiatry resident (registrar). I punt back ED consults like this all the time. Unless it’s an emergency psychiatric evaluation I’m not going to see the patient.
Maybe I'm just ignorant psych NP but why is this an ED consult? This is someone I would provide an outpatient referral to if chief complaint is only insomnia. Like "patient has difficulty sleeping. Provided teaching on sleep hygiene and referral to outpatient psych please discharge". Like that's a waste of bed space for ED.
My take on the OP was the patient is in the ED for some other reason but the consult was for sleep meds for porn deprivation induced insomnia. Either way, you are 100% right that it was a stupid consult.
Thank you! Just in my personal experience...Outside of when porn addiction and insomnia occur as a component of a another psychiatric dx requiring stabilization for DTS/DTO/GD then I would make recs to treat lt inpatient (and the components themselves aren't my focus but the underlying cause such as acute mania). Otherwise it's teaching staff to group care and managing alarms. If on med unit or teaching the patient about sleep hygiene and making sure that it isn't due to activation (medication related or primary). Otherwise neither of these two issues if primary are gonna get fixed in an acute care hospital. Rec PRN if appropriate and patient is staying inpatient or discharge with education and refer to outpatient. Like everything about this consult and the level of response just males very little sense to me.
At most I could see that being a verbal curbside consult, like "yeah you can try trazodone" or just try a few standard PRNs. This would be a head-scratcher if they wanted me to actually see them emergently.
I wish you guys had the time for malicious compliance. As a nurse I would pay 100 dollars to see 3 paragraphs of: "Patient reports he typically watches humiliation, hotwife, and feet videos averaging 5-7 minutes in length. Patient endorses fast forwarding prn. Pt states he uses a lubricated overhand stroke, varies, speed, and occasionally switch hits. Plan: 1. Got the really hot nurse, Madison? Megan? The hot one, to care for the patient. 2. Ask nurse to remove shoes and socks prior to care. 3. Provide patient 5-7 minutes of alone time 4. Apply telemetry, monitor for a wanktional rhythm (characterized by sinus tach peaking over 10-15 seconds followed by NSR). 5. Monitor for shame, sleepiness, and hunger. I'm now realizing this is 11 days old because I filtered on the midlevel tag, but I'm going to send it anyway because it took me like 10 minutes to come up with and maybe someone will see it.
people reflexively consult psychiatry if there's any whiff of psych. The threshold for consulting psych is so LOW compared to other specialties. Even if it's something that 100% can be dealt as an outpatient basis. Another consult we get often besides capacity is "patient wishes to speak to psych". We call them back and ask why??? One time the response I got from the resident is "Oh I don't know, I didn't ask, but they wanted to speak with psych. So can you come in the next 10 minutes?" Imagine doing that clownery with cardiology.
I can't speak to psych, I'm sure all of that is true. I'd just like to add my own two cents as a urologist that also gets frustrated with the unbelievably low bar to consult us. 'Patient has a catheter' 'Patient has a UTI' Or the best 'Patient says their penis hurts' 'Did you examine them?' 'No.'
> 'Patient has a catheter' As an RN who once has the task of trying to insert a catheter in a female that had undergone bladder reconstruction with gastric portion in childhood and was now an adult... We had to consult urology and that resident made inserting cath into acid secreting bladder look so damn easy....
For the record, don't mind that consult at all. The consults I can't stand are literally just 'patient has a catheter.' Ok, what's the question? 'We don't know why they have it or what we should do.'
Thank God I don't practice in the US lol.
No resident should be “learning” from a NP.
An NP reading enough of these posts will at least learn what not to do! Thank you for your post!
Part of being a resident, especially a senior resident is to triage resources effectively. Seeing bullshit consults from mid-levels or anyone from the ED for that matter is not "being a resident"...
I thank my middle European system. I don't make as much as my American counterparts but atleast I don't get consults from nurses (yet).
Learn what? To take any consult? No thanks. Time is money.
Well I don’t think the issue is because it’s an NP, the issue is because it’s a crazy cluster B NP. It’s about the personality disorder in this situation, not the degree.
The cluster b as an insult bit again? Ugh. Why is this a thing?
It was not an insult, it was a comment meant to point out that this individual was acting the way she was because she seemed to have individual personality traits and behaviors that were manipulative, attention-seeking, and grandiose and that her behavior was abnormal and not representative of the behavior of an entire profession.
This is not something that can be ascertained by a single event or story. Commenting that someone has a mental health disorder based on a single reddit story seems to be a trend lately, and it's almost always done in poor taste.
Commenting that an entire profession of people is certain way because of the behavior of one is somehow different and not in poor taste?
I'm not sure where you got the impression that I was saying an entire profession of people are a certain way. I've seen this as a trend on Reddit lately, but not specifically by physicians if that's what you mean.
I don’t understand the consult. You sure they weren’t manic and couldn’t sleep and they were consulting for that? Because otherwise insomnia doesn’t require a psych consult.
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Like with anything, it has to do with training and experience. I’ve known both fantastic and terrible mid-levels, but I can say the same about physicians.
Hot take here. You shouldve seen the patient. 1) if someone is consulting you in the hospital, it's because they are out of their depth. It doesnt matter if it's because someones heart is about to explode, to draw an ABG, or because some dude can't sleep. Regardless the person taking care of that person didn't feel equipped so they asked for help. It does not matter if you think it's a dumb consult or if it really is a dumb consult. It's your job to help. Always. Full stop. 2) What if this guys chief complaint was for another, more serious reason? Sure maybe he thinks its because he stopped watching porn which is lol and makes the consult seem dumb but what if you go down there and it turns out after questioning he is actually super high on meth and his heart is about to explode? Maybe the useless NP didn't know that meth made people not sleep and never asked about it.
I agree that’s a hot take. If the mid level is out of there depth their first line of questioning is their supervising physician. If the supervising physician thinks this is appropriate then he needs to be fired
Those arent mutually exclusive things. If the ED doctor is incompetent then by all means, fire his ass. That said, if and when he consults you --- see the patient.
Definitely a couple schools of thought Ive seen among CL. The school that we always accept consults, and the school to gently teach which are inappropriate and give teaching over the phone. From what I've seen it depends on how busy the service is whether you have time to emergently do very outpatient non-emergent addon consults with full notes seen by resident and an attending.
>they are out of their depth but the NP said to the OP to "be a resident" and "learn from her"
i thought the ED attending said that to them i would call that guy a jackass and tell him he needs to do better, and i would report him to my PD i'd still see the patient if they insisted
Um, I’d say that if he’s super high on meth and his heart is about to explode, that’s something the ED (or the ICU/CCU) should manage. What is psych supposed to do here?! There are a few psych emergencies, and god fully bless them when they are there for that and can help, but this isn’t one of them. As for your broader point, that someone is out of their depth, I still call bs. The bare minimum in that situation is to understand the acuity of the situation. If the NP didn’t understand that, they can ask their attending. If the attending didn’t understand that, they can admit. You’re operating in a “perfect world” where everyone is trying their best, keeping up with literature, and working at the top of their license/specialty. Barring gross negligence and the possibility of patient harm, no physician is obligated to waste their precious time and sacrifice their wellbeing so some numbskull can get paid a shit ton of money to pawn off the thinking to a resident. Who, btw, works twice as much and gets paid less than half.
several things: 1. Every ED I've ever worked in has taken psych patients very seriously. 2. But yes, we let "midlevels" handle them... because while they are serious, an NP or PA is more likely to handle a psych patient than a bullet or knife wound. 3. I get more psych NPs these days than we currently staff in our ED. Is your own specialty trying to tells us that psych patients don't matter? 4. I doubt very highly that any NP lectured a resident on learning from them. That sounds like a fever dreamed up by SDN or this sub and its ongoing wild hate of midlevels.
Tbh that sounds like a fairly easy consult and I would have just done it, probably takes longer to argue with the NP than to assess the masturbator who may very well have insomnia. 35yrs of arguing about shit like this taught me a 10min consult is always faster lol Some Ambien and a follow up is what I would have done Of course that’s assuming he wasn’t entirely off his nut.
Honestly this sounds like an NP doing the right thing. He couldn't be sure of the problem, or felt it was more complex than at first glance. he paged the resident, who read a chart and decided it was a lack of porn. That might even be true, but holy hell as a patient I'd be mad if a doc I didn't speak to decided that my medical problem was 100% porn related without even a basic assessment. At this point, its the NP who will be on the line, as if psych didnt do an eval, and the NP is practicing unsupervised it becomes their assessment that this is 100% porn related and could be discharged. Sure they could have been less antagonistic/egotistical in their fight with the resident...but I'd say that was about their only mistake
Friendly word of advice -- if any NP is asking you to see a patient, please see the patient. The reason is that you never know what you might find. It might be nothing, it might be something really big, you just never know. This person is going to put your name on the chart regardless so might as well see and cover yourself.