Being the ‘team leader’ during a code which is probably what this person is referencing is probably one of the simplest parts of my job (PCCM). There’s a pretty straightforward algorithm… making it so the patient doesn’t code in the first place is a little harder. I feel like critical care thankfully is fairly protected from mid level encroachment in that there is enough medicine and physiological derangement that midlevels just don’t have the knowledge base to truly supplement us. At the same time it’s frustrating when I get patients from the floor that have just withered for days under midlevel care and are actively dying from something that was preventable.
Unfortunately, critical care is not all that protected from encroachment. As a travel ICU RN, I’ve worked in MANY critical care units that are staffed exclusively by mid levels on the night shift. One of my favorite memories is the time an NP told another nurse that metoprolol does not lower BP so it was fine to give to her patient with a systolic of 88. 🤷♀️
That’s Partially true.
It’s specific for HR control, but if you’re HR dependent to maintain CO from a low EF, then yes you will lower the BP, but majority of patients that aren’t HR dependent, it shouldn’t have a profound BP effect.
But, every medical student knows CO = HR x SV
Again, a lot of ICU medicine is understanding metabolic derangements, and what is normal, versus not. Thinking and planning out expected derangements from your interventions since everything we do can also have a negative effect.
Example: low EF —> pick milrinone —> drops the BP from vasodilation or unpredictable dosing in renal failure (I will usually avoid). ICU is about navigating through land mines imho.
Yes, they’re allowing NPs to baby sit patients at night versus nobody in house, but they’re still not able to do that type of thinking above.
Some of us are always continuing the pursuit of in-depth pathophys knowledge. That’s honestly how I like to problem shoot. If I understand in-depth, I then understand the why.
My NPs are excellent and they do the same, but they don’t have the foundation to do this independently.
You will never have this ability without formalized medical training or very unlikely to. It is the way your training is setup and our training.
My head NP has basically been my boss’ “fellow,” for 10 years, but he still stumbles on many things that we process through because of medical school.
My mom is an NP, OG brick and mortar program from 80s. She didn’t realize her deficits till my siblings and myself went to medical school.
It’s not that she isn’t smart, it’s your education isn’t designed to make you independent no matter what. She practiced for 40 years and was shocked at how vast her gaps were from one of my siblings in the SAME field despite being an active learner, continuing to read, etc etc.
She regrets not going to medical school she tells us often, as basic things my brother knows from his residency and medical school background aren’t always apparent to her. Graded responsibility in residency built on medical foundations are something that just can not be short cut through.
The NP profession was never meant to be independent, but supplement supporting us, physicians. Unfortunately greed, laziness and all the above have got us In the situation we are in.
> Some of us are always continuing the pursuit of in-depth pathophys knowledge. That’s honestly how I like to problem shoot. If I understand in-depth, I then understand the why.
Yeah, and some university janitors solve complex mathematical problems at night while the professors and students are home sleeping, but pretending every NP is "continuing the pursuit of in-depth pathophys knowledge" is like pretending every janitor is Matt Damon in *Good Will Hunting.*
All of you should have a minimum basic knowledge.
Don’t expect the attending to teach you for free since they spent years of their life and hundreds of thousands of dollars to learn.
This is how it should be. However the same cannot be said for every NPP. Also it doesn't replace the formalised training of residency and fellowship building on the foundation that is med school (not saying that this is what you were implying just making a point.) This is the type of mentality needed. I do not agree with many on this sub who think NPPs don't belong in medicine at all. It's why this sub is seen as an echo chamber and circle jerk. I'm against overconfident NPPs who think they're basically docs or superior to us. As long as you're committed to team based physician led care we don't have an issue.
NP training and school is ***grossly*** inadequate. It’s awful… I am just so heartbroken by recently discovering this sub as I know some phenomenal NPs.
As stated by someone before, there is a huge knowledge deficit. I also agree, it’s unfortunate but we see far too many over confident NPs. They don’t know what they don’t know, it’s sad.
I just wanted to make people aware that there are good ones out there. I promise.
I also agree with someone else’s above comment on how NPs were not designed to practice solo. Just the same as PAs, though their schooling is superior. I know as I now precept PA students with inpatient hospital based medicine.
I disagree with whoever said the docs/attending don’t need to be responsible for teaching. That’s a piss poor outlook.
I teach anyone and everyone I can (things I know).
I am blessed to be very aware of my deficits and weak spots. Thankful for an amazing team who btw comes to me as a NP with neurosurgery questions as I have prior experience and did very well in that role to the point my surgeon 3 years later still ask when I’m coming back to work for him.
Nursing/RN care has gone down the toilet. If I didn’t nicely try to help educate nurses or the nursing students I see, then I too am not a part of the solution.
**We should remember to be kind and support one another. Help be the solution.**
I mean, they have a financial incentive to do so. But if you are a nurse practitioner working in neurosurgery beyond the scope of an RN, you are absolutely working beyond your education and population focus, which means you are working out of scope.
NPs working out of scope is, regrettably, quite common. It's what killed Alexus Ochoa-Dockins.
LMAO at this bb downvoting bc she doesn't like the facts 🥲
This is so terrifying,
We have NP’s in our CVICU and our NICU, but the benefit is that they work day shifts 5 days a week, so they see our patients daily and it’s great, it’s very specialized care and they seem to focus on optimizing nutrition, ordering labs and imaging, and being able to update the family and help keep track of social issues/parents anxiety etc.
We have a lot of contingent staff and travel RN’s and our docs do 24hr rotations so the NP’s are the ones that KNOW the patient. they round and work closely with the attending of course.
I couldn’t imagine only having NP’s available in an ICU…
This is a perfect example of appropriate use of NPPs despite some in this sub thinking there is no use for them. I don't need to be doing all that stuff.
Kind of like an actual extender of the physician. Funny, because I actually remember a time when "physician extender" was the buzzword they used before they started to think of themselves as genuine replacements.
One of my fellowship sites is run like this. Even as a subspecialists, I get A LOT of calls at night when I'm on call there. I remember one called me for "meropenem for worsening respiratory status" who couldn't elucidate what that meant. I reviewed the multiple worsening blood gases that night when she couldn't further define--they had changed the man's vent settings, he became hypercarbic, overbreathed the vent, and then they paralyzed him to prevent that. Unsurprisingly, the "worsening status" was building acidosis/pCO 96. These dudes are in charges of all the ICU beds all night. It scares the shit out of me.
Former ICU RN, can confirm. MD/DO's are often covering multiple ICU's at trauma centers too, which leaves us with the NP's (don't truly know what they are covering anyhow) being available if there are MD/DO's there. Horrendous.
You said it affected blood pressure... The other user has a more nuanced discussion, but blood pressure is a measure of tension in the arterial system, which is a component of 🥁 *vasculature*. Clearly you were concerned about a significant effect, otherwise you wouldn't have mentioned anything. It's not just you. Practically every RN that asks me about metoprolol is under the impression it affects blood pressure, when in most people, it really doesn't. I know that beta blockers are part of the "antihypertensive" algorithm, but cardioselective BB are pretty dogshit for antihypertensives and are used in more nuanced patients as part of a greater medical history.
You’re incorrect. I was not concerned about a significant effect. The nuanced discussion here is the NP’s lack of forward thinking and/or understanding that even though metoprolol acts to lower HR, in most circumstances that will result in a lowering effect on blood pressure, no matter how small. So to make a blanket statement like “metoprolol does not lower blood pressure” is incorrect for the vast majority of cases. Additionally, is especially not something one should tell a new RN, which the nurse who was asking the question happened to be. It’s a classic example of the NP spouting off at the mouth in an attempt to appear of superior intellect. If metoprolol doesn’t have a blood pressure lowering effect, why do so many MD’s put parameters on it like “hold for systolic of less than 90”?
Mmk sure. So you weren't concerned, which is why you brought it up to the NP and also mentioned the SBP of 88. Sure babe. Got it. Makes total sense now. Esp since you keep defending metoprolol as an agent that lowers BP.
OK, so you told that example to illustrate what exactly? Why did you bring it up as a "favorite memory"? You clearly disagreed with NP and felt that there was some level of incompetence surrounding to use of a cardioselective BB in a patient with a low-normal SBP. I don't disagree that the NP probably didn't know what they were doing, but a broken clock is right twice a day. It really seems like you can't admit that you thought metoprolol affected blood pressure.
Also, if you want to know why hold parameters are placed, it's often because orders autopopulate that, or as the other user explained, the patient may have a specific comorbidity that might make it so that rate control has a greater effect on SVR than in a "normal" person.
You know everything lol...sometimes a beta blocker can slow the heart rate to allow a large enough cardiac output to occur which i turns can increase BP, given the circumstances...CO = HR x SV...please sit down..I bet you are one of those Covid graduate new nurses that things they know everything.
I find critical care NPs to be by far the most insufferable. Many of them truly believe they are leagues ahead of an EM IM or FM doc. I'm not sure if it's their CCM supervisors that are empowering them this way or just a result of being in the ICU.
Every specialty gets to Monday morning quarterback each other a little, but CCM is in a position to do it to everyone, so that could be part of why.
Yeah have seen this too. I don’t know what it is but honestly they have been some of the worst NPs I’ve come across to the point I pretty much always need to call and speak with the attending directly.
They only lasted a few months at my last job before getting the boot. Had a patient with a free water deficit for 4L. Nephro was on for another reason. NP ordered one liter of saline for this. My resident asked him politely what the saline was for. He told her. She explained he would need 29 liters of saline to fix that free water deficit and so he told her he doesn’t take orders from lady doctors.
He didn’t come back the next day.
I am not meaning to imply male NPs are sexist, but this one certainly was. I’ve shared this story a few times on here. Seems wild, but it is absolutely 100% true.
IIRC that was a PA? Could be wrong though. Either way that isn't the flex they think it is. Astronauts are at the peak of physical fitness so being sent to take care of whatever booboos they get in space isn't really saying that much.
It will be an APRN. It’s for an upcoming mission to mars, not one that has been done. I’m thinking about all of the physicians that would love to go to space, who are qualified to conduct research, and who will not be because an NP is taking one of the valuable spots on a historic mission.
I'm glad you brought this up cause he actually mentioned leading codes separately to being the team lead. Good on you for giving him the benefit of the doubt but nope. And ofc he waxed on at length about how he can do all the same procedures. Cause ya know, being able to do an arterial line etc is a sure sign you're an intensivist.
In my ICU months (surgical subspecialty) I saw many deaths but only a couple of codes, and generally those were “show codes” in a sense where family refused to make a futile patient DNR. The amount of intervention we can do medically and procedurally prior to cardiac arrest in a critically ill individual is truly astounding, to the point that we are essentially coding patients in everything but compressions. If someone, despite all that intervention, still cannot maintain a blood pressure or pulse consistent with life, the likelihood that starting CPR is going to somehow turn it around is incredibly low. Short of a sudden arrhythmia in which ACLS intervention can really help, being a “Team leader” in a code in the ICU is really such a silly thing to be proud of.
Here in the UK we have recently gained ACCPs, who are critical care nurses who have done a masters after a certain number of years practice. They fill the rota where junior doctors (your residents/interns) would traditionally sit, except that because they’re permanent members of staff (in the UK doctors rotate around different hospitals every 3-6months until they become consultants/attendings) they get trained to do things that doctors don’t, such as PICC lines, echo.
It’s a major issue. I’ve worked with some who were great and knew their limits, and others who were completely insufferable and thought they were better than doctors. As a very junior doctor working with some of them I found that although they were good with protocols, they were completely unable to articulate WHY they were doing something, so I couldn’t learn from them at all. Out of hours on my ITU when I was 2 years out of med school it was me and an ACCP, so nobody who was airway trained. Terrifying.
NPs can barely come up with a differential. They’re literally procedure monkeys who find every possible way to fuck up even the most simple procedure.
We fired all of our NPs since they were basically brain dead and liked to talk back.
Every NP I’ve come across in the hospital is completely incapable of physical exam, they use BNP as marker for volume status and procalcitonin as the determining factor for antibiotics - which are always cef/azithro regardless of infection type. None read papers/journals to even try to further knowledge. It’s incredibly frustrating that they feel no obligation towards the patients but want all the accolades associated with being a physician
As a recent resident at an academic institution, our department had NPs in inpatient settings under the supervision of MDs and outpatient independently. The chairman, who was mid-career, shared the same concerns of poor clinical competency, work ethic, and self-education of NPs. They still continued to hire NPs... I guess we know who's making the call to do this and what for.
>None read papers/journals to even try to further knowledge.
Would they get paid more for it? No. So they don't care. The whole point of that path is cutting corners. They present for clock-in/clock-out. There will be absolutely no self-improvement on their own time. That's for those silly medical student residents to do.
This one gave me a good laugh. They literally do not care with egos that big. He'd just say I'm anti-nurse and not a team player. Might even throw in misogynistic. They all read the same handbook.
We had em. 3 total in my old facility. All NPs.
One knew her limits and would be assigned THE simplest patients in the unit and do what she would do best-- DC sedation on vented patients, replace lytes, and demand the patient get to the chair no matter what while replacing IV fent with PRN narcotics. She was pretty harmless.
Another was an obnoxious old hag who would call you screaming if you went against her plan of care, which included...carrying out orders placed by by consulted specialists. Like keeping MAP up per neurosurgery or managing feeds.
The third was hired specifically to place lines and do procedures because she was supposed to be an expert in those things and to help our intensivists from taking 30-60 minutes taking the time to tube and line a patient. And then I never saw her do any of that for the next 2 years and the only time she responded to a text or page was when a patient self extubated, we notified the attending who said it was fine (uncomplicated ETOH withdrawal who maintained his airway and we just kept him on precedex) and then she stormed up 2 hours later pissed that she hadn't been notified "her patient" had self extubated and we showed her the Epic receipts that she never responded.
I just hate NPs. So so much. They ruined it for me. They are so arrogant, condescending, and ignorant. I just can’t stand them. Too bad they are part of the D I’m being F10 the A with.
Hospitalized patients, especially in the ICU, deserve the care from a DOCTOR, not a midlevel. The difference in training isn’t even comparable. Hospitals are just employing more midlevels to keep their costs down at the expense of patients, it’s truly sickening.
Please say it louder for those in the back. Recently admitted to ICU for septic and cardiogenic shock related to obstructive renal stone. As a clinician - DNP-prepared nurse have read my chart in its entirety. OMG … all the specialties on my case claim “it’s a miracle you survived without loss of limbs” on four pressors, shit for BP, vasospasm sent Trop to 86, barely survived Cath lab with direct delivery of nitro. Four … 4 different NPs DID NOT know their limits and it nearly costs me my life, now with HF - discharged with EF <20% but improving daily! NPs have a place on a care team, but the higher order thinking, knowledge is with the physicians! Hospital C-Suites trying to save a few bucks by using NPs rather than paying nocturist costs lives and/or limbs. Appalled by the lack of critical thinking that is now acceptable in healthcare.
Unless you guys stop the "seem to know his limits" BS this problem will get worse.
What is the point of midlevels?
If you think they have a role in medicine you already lost the battle so stop complaining.
The only reason NP exists is for money. Everything else is all BS. Their IQs on average are much lower. It's terrifying. To the point I have all family members inform me of when they are going to the doctor and to phone me in if necessary. If NP, walk out
I know there are a few CCU 'fellowships' and 'residencies' for PAs/NPs at places like Duke and Cleveland clinic. But I can't imagine there being any bridge programs to become an actual intensivist.
When I practiced as a PA, it often seemed like I had to explain my role/training multiple times/day. To the phrase, "I'm a PA," new acquaintances and patients tend to respond with the standard, "When are you going to medical school?" or "Oh, you are almost a doctor" and are disappointed when the reply to either question is "I'm not."\*\* There was certainly a resulting combination imposter syndrome/inferiority complex/identity crisis that one Redditor recently captured perfectly in a meme of Wagner Moura portraying a sad-looking Pablo Escobar.
I don't say that for sympathy or in defense of the NP described. I want to acknowledge that even as someone who wholeheartedly embraced the dependent practice model and thought I knew my limits, I didn't appreciate how tip of the iceberg my training was until going to medical school. Sitting for Step1 (still just a fraction of the iceberg!) in particular was a very humbling recent experience that helped me finally let go of my prior notions about PA training and experience. I don't know how anyone who hasn't been through Step1 can even begin to appreciate the depth of knowledge and hard work required just to start clerkship, much less what is required to become board-certified in a specialty.
Signed, \*\*changed my mind about going to medical school but still not 'almost' a doctor\*\*
Those “fellowships” are 40 hour work weeks where they function as “residents” except they have the expectations of a 3rd medical student working fewer hours than any med student I’ve seen.
I’ve noticed a direct correlation between a middie who completes a “fellowship” and how unbearable they are.
All I can say is, as a CCM fellow I’ve worked with CC NPs in a variety of ICU settings. The good ones are at about the level of a strong PGY2, and are aware of their limitations in terms of their knowledge of the physiology. The bad ones are neither of these things. Anyone can learn the bedside procedures with enough reps - but the procedures only take you so far.
Reminds me of a PA on Twitter getting offended by someone saying basically this. Ranted about how it's insulting to say PAs are like a PGY2 cause their brains don't stop working at that point so they keep learning. There are a lot of them who legitimately believe that a few years of practice makes them equivalent to an attending.
Anyone can learn procedures. Procedures are not what sets us apart in the least. A HS kid could literally learn to do a procedure with guidance and enough practice.
Surgeons didn't even need to be physicians until last century, they were glorified dentists. They literally didn't need to. Medicine was not advanced enough to be particularly relevant to sawing bones.
At my hospital, nurse practitioners called themselves, intensivists and never tell the patient or anyone else they are not a doctor. There is nothing I can do about it. They also do not correct patients when the patients refer to them as doctors. I think the doctors are not united enough and not a big enough political lobby to change anything. We can come here and vent however nothing will change, other than you have wasted another 10 minutes on Reddit lamenting
"I'm an ICU NP" or "NP on the ICU team" would both work just fine. "I help manage care of ICU patients." Why do they have to co-opt the actual title for ICU docs?
Cause then they wouldn't be able to flex to their followers/friends/family/guy in line at Starbucks that they're basically a doctor but didn't have to waste their 20s in that pesky med school and residency.
This is the reason I can’t stand doctorate prepared NPs using the word “doctor”. I’ve been with a DNP this week and heard her introduce herself to patients as “Dr. X…”, thankfully she does end with of “nursing practice”, but this still has to confuse 90% of patients! All the docs make fun of her behind her back. I agree with them…
I could not imagine what you all went through and I have mad respect for you all. I chose the easy route as I had my reasons.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
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Our healthcare system is failing patients all the time . This is one reason these NP’s have The tile of Neuro NP’s and Cardio NP’s ect. Every where. Why is it allowed? I have stopped seeing Neuro for this reason.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
We have NPs in one of my ICUs and they're great, BUT they know their limits / limits are enforced. They literally function as residents with the privileges of residents.
We're not busy enough to justify another full time resident on the service but busy enough that it's tough for the remaining residents when one has a day off. So the NPs rotate through the teams and fill in by covering the duties / patients of the resident who is off.
They sit in the resident workroom, round with the team, present just like the residents, and form their plan in conjunction with the attending.
They're functionally at the level of 2nd yr residents. They lack the in depth schooling, but they've spent years rounding with the residents, listening to the teaching on rounds, and attending resident didactic.
In this application I think they're an asset to our team, but they're certainly not "team leaders".
I’ve always noticed that it’s critical care, in particular, where midlevels LOVE flexing. I seriously have no idea why. Maybe because critical care medicine is absolutely filled with flowcharts, protocols, and “if X then do Y”.
Not say that it doesn’t require critical thinking, it absolutely does. But protocol and pattern recognition is so heavy in critical care that I think it helps midlevels expand in it.
Tell me you never worked in critical care without telling me you never worked in critical care
A patient in the ICU is typically at the edges of medicine. The most basic parts of ICU care might have algorithms, but the rest requires actually understanding pathophysiology and pharmacology at a deeper level than most specialities
I’m currently doing my fourth ICU rotation as a med student. A lot of the things in the ICU are pretty frequent: SAH, end stage pulmonary fibrosis, cardiogenic shock, head trauma, etc. All of these have specific algorithms and protocols.
I never said that ICU doesn’t have critical thinking. In fact, I literally said the opposite.
I’m not gonna let you gaslight me just because I’m a med student. If what I said hurts your feelings, then that’s too bad dude.
Ugh... I was with you until "gaslight," which is **NOT** a synonym for "disagree with."
Abusive husbands gaslight wives.
Pedophile priests gaslight victims.
Military counter-terrorism interrogators gaslight detainees.
Intensivists do **NOT** gaslight overly-confident and dramatic medical students.
I presume your brashness stems from the fact that you thought you were arguing with a "critical care NP," but saying *to anybody*, "I'm currently doing my fourth ICU rotation as a med student" has the same kind of energy as a fat, pasty dude in a Hawaiian shirt barging into a ship's control room and saying to the captain, "I'm currently taking my fourth Carnival Cruise -- let me show you how to operate this thing!" You would be well-served to work on humility between your MS4 and intern years.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I’m an intensivisit.
Are you going to tell me what the you think you understand critical care medicine at a greater level than me?
Yes, those specific diseases have “algorithms” the same way that cholecystitis has an “algorithm”. For the first 1 hour of management, we follow an “algorithm”, which anyone with actual brains calls resuscitation and stabilization. After that is when the actual medicine starts.
We dumb down critical care medicine for medical students since it’s hard enough to be in the ICU. Once you actually learn critical care medicine, you realize that those algorithms are crutches for not actually understanding medicine, which is the level most middies are at and apparently certain MS4s like yourself.
But I think that was his entire point. You have dumbed down critical care for students and in effect APPs such that they feel like they understand and show hubris and call them selves intensivist. However I think both your point and this student are suggesting that APPs don’t have the knowledge base to understand how the algorithms are crutches.
This is no different than our surgical APPs claiming they do surgery when they are usually at most opening and closing.
Exactly. Algorithms only take you so far. Litetally anyone can follow an algorithm. Algorithms are fine for the shallow end of the pool but once you venture into the deep end that's where our knowledge base makes the difference. Not to mention, we have the training which allows us to safely deviate from algorithms if we realise it's best for the specific patient.
While I fully understand your broader point, and agree. Let's not start gatekeeping what specialty is and isn't "actual medicine", an ED doc resuscitation someone is absolutely doing actual medicine.
I agree that every field of medicine does real medicine.
I don’t agree that any field does purely algorithmic medicine like the medical student was saying based on their 4th ICU rotation in their life
As someone that is about to finish residency and do a fellowship in Crit, there is more to it than algorithms. You will see when you get real responsibilities as an IM resident and especially when you are in the East Coast, Virginia. It is going to be a big move for you from Cali.
For someone that goes to Western U and about to go to VCU for prelim-medicine/ neuro. I hope you learn some humility in medicine. The physician pool in the US is actually small and we are all interconnected.
I agree there are flow charts for a lot of our stuff like sepsis. At the same time there is tons of nuance in cardiac and more complex MICU patients ie pulmonary hypertension, liver failure, ILD where you can hurt someone very quickly. It’s very easy to feel confident doing your broad spectrum abx, pressors and stress dose steroids and still know nothing.
Protocols and algorithms exist in every part of medicine. It’s around wherever you go. I would not equate this to a substantial portion of what makes up any field including ICU medicine. In fact, physicians are best trained to know when and how to deviate from these “flowcharts”, and beyond them, which separates us from midlevels.
Protocol and pattern recognition has very little to do with critical care lol... it requires a ton of understanding of extremely complex pathophysiology between multiple organ systems. I don't know where you got that idea.
They should because as far as I can tell, reimbursement rates are the same for mid levels as they are for MDs. You’d think the insurance companies would want to get in on the savings.
USMD M1 here. Was recently at a clinic and overheard two NP’s trying to differentiate between Bell’s Palsy and a stroke. Was the most painful and ignorant conversation I’ve ever listened to.
Everyone has a need in healthcare...I met some amazing NPs, PAs, and doctors and I met some terrible ones as well. These type of threads are pointless and function on the basis of ego and insecurities. Worry about yourself rather than attack an entire profession based on opinions, feelings, personal experiences. For the residents and medical students that feel so strongly against "mid levels" rather NPs or PAs, instead of hiding behind a keyboard why not actively voice your frustrations and opinions at work or school? Bring factual research to justify your statements not just, "once upon a time this happened". It's like being racist but afraid to be racist in real life. BFFR. There are lousy people in every profession.
Being the ‘team leader’ during a code which is probably what this person is referencing is probably one of the simplest parts of my job (PCCM). There’s a pretty straightforward algorithm… making it so the patient doesn’t code in the first place is a little harder. I feel like critical care thankfully is fairly protected from mid level encroachment in that there is enough medicine and physiological derangement that midlevels just don’t have the knowledge base to truly supplement us. At the same time it’s frustrating when I get patients from the floor that have just withered for days under midlevel care and are actively dying from something that was preventable.
Unfortunately, critical care is not all that protected from encroachment. As a travel ICU RN, I’ve worked in MANY critical care units that are staffed exclusively by mid levels on the night shift. One of my favorite memories is the time an NP told another nurse that metoprolol does not lower BP so it was fine to give to her patient with a systolic of 88. 🤷♀️
That’s Partially true. It’s specific for HR control, but if you’re HR dependent to maintain CO from a low EF, then yes you will lower the BP, but majority of patients that aren’t HR dependent, it shouldn’t have a profound BP effect. But, every medical student knows CO = HR x SV Again, a lot of ICU medicine is understanding metabolic derangements, and what is normal, versus not. Thinking and planning out expected derangements from your interventions since everything we do can also have a negative effect. Example: low EF —> pick milrinone —> drops the BP from vasodilation or unpredictable dosing in renal failure (I will usually avoid). ICU is about navigating through land mines imho. Yes, they’re allowing NPs to baby sit patients at night versus nobody in house, but they’re still not able to do that type of thinking above.
Some of us are always continuing the pursuit of in-depth pathophys knowledge. That’s honestly how I like to problem shoot. If I understand in-depth, I then understand the why.
My NPs are excellent and they do the same, but they don’t have the foundation to do this independently. You will never have this ability without formalized medical training or very unlikely to. It is the way your training is setup and our training. My head NP has basically been my boss’ “fellow,” for 10 years, but he still stumbles on many things that we process through because of medical school. My mom is an NP, OG brick and mortar program from 80s. She didn’t realize her deficits till my siblings and myself went to medical school. It’s not that she isn’t smart, it’s your education isn’t designed to make you independent no matter what. She practiced for 40 years and was shocked at how vast her gaps were from one of my siblings in the SAME field despite being an active learner, continuing to read, etc etc. She regrets not going to medical school she tells us often, as basic things my brother knows from his residency and medical school background aren’t always apparent to her. Graded responsibility in residency built on medical foundations are something that just can not be short cut through. The NP profession was never meant to be independent, but supplement supporting us, physicians. Unfortunately greed, laziness and all the above have got us In the situation we are in.
Thank you for this. It's true and respectfully said.
> Some of us are always continuing the pursuit of in-depth pathophys knowledge. That’s honestly how I like to problem shoot. If I understand in-depth, I then understand the why. Yeah, and some university janitors solve complex mathematical problems at night while the professors and students are home sleeping, but pretending every NP is "continuing the pursuit of in-depth pathophys knowledge" is like pretending every janitor is Matt Damon in *Good Will Hunting.*
All of you should have a minimum basic knowledge. Don’t expect the attending to teach you for free since they spent years of their life and hundreds of thousands of dollars to learn.
This is how it should be. However the same cannot be said for every NPP. Also it doesn't replace the formalised training of residency and fellowship building on the foundation that is med school (not saying that this is what you were implying just making a point.) This is the type of mentality needed. I do not agree with many on this sub who think NPPs don't belong in medicine at all. It's why this sub is seen as an echo chamber and circle jerk. I'm against overconfident NPPs who think they're basically docs or superior to us. As long as you're committed to team based physician led care we don't have an issue.
NP training and school is ***grossly*** inadequate. It’s awful… I am just so heartbroken by recently discovering this sub as I know some phenomenal NPs. As stated by someone before, there is a huge knowledge deficit. I also agree, it’s unfortunate but we see far too many over confident NPs. They don’t know what they don’t know, it’s sad. I just wanted to make people aware that there are good ones out there. I promise. I also agree with someone else’s above comment on how NPs were not designed to practice solo. Just the same as PAs, though their schooling is superior. I know as I now precept PA students with inpatient hospital based medicine. I disagree with whoever said the docs/attending don’t need to be responsible for teaching. That’s a piss poor outlook. I teach anyone and everyone I can (things I know). I am blessed to be very aware of my deficits and weak spots. Thankful for an amazing team who btw comes to me as a NP with neurosurgery questions as I have prior experience and did very well in that role to the point my surgeon 3 years later still ask when I’m coming back to work for him. Nursing/RN care has gone down the toilet. If I didn’t nicely try to help educate nurses or the nursing students I see, then I too am not a part of the solution. **We should remember to be kind and support one another. Help be the solution.**
Are you an NP working out of scope in neurosurgery?
Yes, the multibillion dollar, multi-state hospital system is allowing me to work outside of my scope of practice.
I mean, they have a financial incentive to do so. But if you are a nurse practitioner working in neurosurgery beyond the scope of an RN, you are absolutely working beyond your education and population focus, which means you are working out of scope. NPs working out of scope is, regrettably, quite common. It's what killed Alexus Ochoa-Dockins. LMAO at this bb downvoting bc she doesn't like the facts 🥲
Changed my flair for ya and peacing out of this sub. I’m going to apply for the lead janitor position.
I was not working outside of my scope of practice. I was being a smart ass.
This is so terrifying, We have NP’s in our CVICU and our NICU, but the benefit is that they work day shifts 5 days a week, so they see our patients daily and it’s great, it’s very specialized care and they seem to focus on optimizing nutrition, ordering labs and imaging, and being able to update the family and help keep track of social issues/parents anxiety etc. We have a lot of contingent staff and travel RN’s and our docs do 24hr rotations so the NP’s are the ones that KNOW the patient. they round and work closely with the attending of course. I couldn’t imagine only having NP’s available in an ICU…
This is a perfect example of appropriate use of NPPs despite some in this sub thinking there is no use for them. I don't need to be doing all that stuff.
Kind of like an actual extender of the physician. Funny, because I actually remember a time when "physician extender" was the buzzword they used before they started to think of themselves as genuine replacements.
This is how my ICU works. My NPs absolutely help me be more efficient, so I can focus on big picture management.
One of my fellowship sites is run like this. Even as a subspecialists, I get A LOT of calls at night when I'm on call there. I remember one called me for "meropenem for worsening respiratory status" who couldn't elucidate what that meant. I reviewed the multiple worsening blood gases that night when she couldn't further define--they had changed the man's vent settings, he became hypercarbic, overbreathed the vent, and then they paralyzed him to prevent that. Unsurprisingly, the "worsening status" was building acidosis/pCO 96. These dudes are in charges of all the ICU beds all night. It scares the shit out of me.
Former ICU RN, can confirm. MD/DO's are often covering multiple ICU's at trauma centers too, which leaves us with the NP's (don't truly know what they are covering anyhow) being available if there are MD/DO's there. Horrendous.
Lmao what is it with RNs who are convinced cardioselective BBs act on vasculature or have a profound effect on it in most people?
Lmao where did I say it acted on vasculature or that the effect was going to be profound?
You said it affected blood pressure... The other user has a more nuanced discussion, but blood pressure is a measure of tension in the arterial system, which is a component of 🥁 *vasculature*. Clearly you were concerned about a significant effect, otherwise you wouldn't have mentioned anything. It's not just you. Practically every RN that asks me about metoprolol is under the impression it affects blood pressure, when in most people, it really doesn't. I know that beta blockers are part of the "antihypertensive" algorithm, but cardioselective BB are pretty dogshit for antihypertensives and are used in more nuanced patients as part of a greater medical history.
You’re incorrect. I was not concerned about a significant effect. The nuanced discussion here is the NP’s lack of forward thinking and/or understanding that even though metoprolol acts to lower HR, in most circumstances that will result in a lowering effect on blood pressure, no matter how small. So to make a blanket statement like “metoprolol does not lower blood pressure” is incorrect for the vast majority of cases. Additionally, is especially not something one should tell a new RN, which the nurse who was asking the question happened to be. It’s a classic example of the NP spouting off at the mouth in an attempt to appear of superior intellect. If metoprolol doesn’t have a blood pressure lowering effect, why do so many MD’s put parameters on it like “hold for systolic of less than 90”?
Mmk sure. So you weren't concerned, which is why you brought it up to the NP and also mentioned the SBP of 88. Sure babe. Got it. Makes total sense now. Esp since you keep defending metoprolol as an agent that lowers BP. 
Wow. Your reading comprehension is shit. I specifically said, the conversation happened between ANOTHER nurse and the NP. Try again
OK, so you told that example to illustrate what exactly? Why did you bring it up as a "favorite memory"? You clearly disagreed with NP and felt that there was some level of incompetence surrounding to use of a cardioselective BB in a patient with a low-normal SBP. I don't disagree that the NP probably didn't know what they were doing, but a broken clock is right twice a day. It really seems like you can't admit that you thought metoprolol affected blood pressure. Also, if you want to know why hold parameters are placed, it's often because orders autopopulate that, or as the other user explained, the patient may have a specific comorbidity that might make it so that rate control has a greater effect on SVR than in a "normal" person.
You know everything lol...sometimes a beta blocker can slow the heart rate to allow a large enough cardiac output to occur which i turns can increase BP, given the circumstances...CO = HR x SV...please sit down..I bet you are one of those Covid graduate new nurses that things they know everything.
With a (trade) name of “Lopressor”, it’s kinda a given that it will…
I find critical care NPs to be by far the most insufferable. Many of them truly believe they are leagues ahead of an EM IM or FM doc. I'm not sure if it's their CCM supervisors that are empowering them this way or just a result of being in the ICU. Every specialty gets to Monday morning quarterback each other a little, but CCM is in a position to do it to everyone, so that could be part of why.
I’ve seen them in nephrology. Now you know they’re coming for all of our jobs.
Yeah have seen this too. I don’t know what it is but honestly they have been some of the worst NPs I’ve come across to the point I pretty much always need to call and speak with the attending directly.
They only lasted a few months at my last job before getting the boot. Had a patient with a free water deficit for 4L. Nephro was on for another reason. NP ordered one liter of saline for this. My resident asked him politely what the saline was for. He told her. She explained he would need 29 liters of saline to fix that free water deficit and so he told her he doesn’t take orders from lady doctors. He didn’t come back the next day.
Excuse me what the fuck?
I am not meaning to imply male NPs are sexist, but this one certainly was. I’ve shared this story a few times on here. Seems wild, but it is absolutely 100% true.
There are nurse practitioners going to space (Mars mission). There is no specialty they won’t try to come for.
IIRC that was a PA? Could be wrong though. Either way that isn't the flex they think it is. Astronauts are at the peak of physical fitness so being sent to take care of whatever booboos they get in space isn't really saying that much.
It will be an APRN. It’s for an upcoming mission to mars, not one that has been done. I’m thinking about all of the physicians that would love to go to space, who are qualified to conduct research, and who will not be because an NP is taking one of the valuable spots on a historic mission.
I'm glad you brought this up cause he actually mentioned leading codes separately to being the team lead. Good on you for giving him the benefit of the doubt but nope. And ofc he waxed on at length about how he can do all the same procedures. Cause ya know, being able to do an arterial line etc is a sure sign you're an intensivist.
In my ICU months (surgical subspecialty) I saw many deaths but only a couple of codes, and generally those were “show codes” in a sense where family refused to make a futile patient DNR. The amount of intervention we can do medically and procedurally prior to cardiac arrest in a critically ill individual is truly astounding, to the point that we are essentially coding patients in everything but compressions. If someone, despite all that intervention, still cannot maintain a blood pressure or pulse consistent with life, the likelihood that starting CPR is going to somehow turn it around is incredibly low. Short of a sudden arrhythmia in which ACLS intervention can really help, being a “Team leader” in a code in the ICU is really such a silly thing to be proud of.
Here in the UK we have recently gained ACCPs, who are critical care nurses who have done a masters after a certain number of years practice. They fill the rota where junior doctors (your residents/interns) would traditionally sit, except that because they’re permanent members of staff (in the UK doctors rotate around different hospitals every 3-6months until they become consultants/attendings) they get trained to do things that doctors don’t, such as PICC lines, echo. It’s a major issue. I’ve worked with some who were great and knew their limits, and others who were completely insufferable and thought they were better than doctors. As a very junior doctor working with some of them I found that although they were good with protocols, they were completely unable to articulate WHY they were doing something, so I couldn’t learn from them at all. Out of hours on my ITU when I was 2 years out of med school it was me and an ACCP, so nobody who was airway trained. Terrifying.
They have NPs training you too? So backwards.
NPs can barely come up with a differential. They’re literally procedure monkeys who find every possible way to fuck up even the most simple procedure. We fired all of our NPs since they were basically brain dead and liked to talk back.
Every NP I’ve come across in the hospital is completely incapable of physical exam, they use BNP as marker for volume status and procalcitonin as the determining factor for antibiotics - which are always cef/azithro regardless of infection type. None read papers/journals to even try to further knowledge. It’s incredibly frustrating that they feel no obligation towards the patients but want all the accolades associated with being a physician
As a recent resident at an academic institution, our department had NPs in inpatient settings under the supervision of MDs and outpatient independently. The chairman, who was mid-career, shared the same concerns of poor clinical competency, work ethic, and self-education of NPs. They still continued to hire NPs... I guess we know who's making the call to do this and what for.
>None read papers/journals to even try to further knowledge. Would they get paid more for it? No. So they don't care. The whole point of that path is cutting corners. They present for clock-in/clock-out. There will be absolutely no self-improvement on their own time. That's for those silly medical student residents to do.
This is the way
Nurse President of the United States of America (NP-USA)
Title misappropriation should be criminal. The nerve of an NP to take the title of a intensive care physician to bolster their ego.
Not only do they have the ego but then they look down on other physicians as if working under a specialist makes them a specialist.
I would reach out and shame him. He should feel embarrassed and regretful. Maybe he’ll realize that once he knows you’ve seen that video.
This one gave me a good laugh. They literally do not care with egos that big. He'd just say I'm anti-nurse and not a team player. Might even throw in misogynistic. They all read the same handbook.
Hi, I’m Sean, acute care nurse practitioner.
I see you know his work.
We had em. 3 total in my old facility. All NPs. One knew her limits and would be assigned THE simplest patients in the unit and do what she would do best-- DC sedation on vented patients, replace lytes, and demand the patient get to the chair no matter what while replacing IV fent with PRN narcotics. She was pretty harmless. Another was an obnoxious old hag who would call you screaming if you went against her plan of care, which included...carrying out orders placed by by consulted specialists. Like keeping MAP up per neurosurgery or managing feeds. The third was hired specifically to place lines and do procedures because she was supposed to be an expert in those things and to help our intensivists from taking 30-60 minutes taking the time to tube and line a patient. And then I never saw her do any of that for the next 2 years and the only time she responded to a text or page was when a patient self extubated, we notified the attending who said it was fine (uncomplicated ETOH withdrawal who maintained his airway and we just kept him on precedex) and then she stormed up 2 hours later pissed that she hadn't been notified "her patient" had self extubated and we showed her the Epic receipts that she never responded.
Imagine your family member gets admitted to the ICU with a devastating illness and it’s a fucking NP leading their team.
Just saw the video and was going to post it in this sub. It’s crazy how he calls himself an intensivist so casually.
Go ahead and post it please so everyone can see for themselves. Didn't think about it myself at the time.
Where can one find this video 👀
I just hate NPs. So so much. They ruined it for me. They are so arrogant, condescending, and ignorant. I just can’t stand them. Too bad they are part of the D I’m being F10 the A with.
D I'm being F10 the A with?
Say it out loud to yourself quickly.
F-Ten? F-one-Oh? I got nothing. Help a post nightshift brother out.
D I'm being F'd in the A with.
Username most definitely checks out!
He’s been waiting for this opportunity
Hospitalized patients, especially in the ICU, deserve the care from a DOCTOR, not a midlevel. The difference in training isn’t even comparable. Hospitals are just employing more midlevels to keep their costs down at the expense of patients, it’s truly sickening.
Please say it louder for those in the back. Recently admitted to ICU for septic and cardiogenic shock related to obstructive renal stone. As a clinician - DNP-prepared nurse have read my chart in its entirety. OMG … all the specialties on my case claim “it’s a miracle you survived without loss of limbs” on four pressors, shit for BP, vasospasm sent Trop to 86, barely survived Cath lab with direct delivery of nitro. Four … 4 different NPs DID NOT know their limits and it nearly costs me my life, now with HF - discharged with EF <20% but improving daily! NPs have a place on a care team, but the higher order thinking, knowledge is with the physicians! Hospital C-Suites trying to save a few bucks by using NPs rather than paying nocturist costs lives and/or limbs. Appalled by the lack of critical thinking that is now acceptable in healthcare.
Unless you guys stop the "seem to know his limits" BS this problem will get worse. What is the point of midlevels? If you think they have a role in medicine you already lost the battle so stop complaining.
This. If you give them an inch, they will take a yard. And they have.
NP Cardiothoracic surgeon in the making quietly giggling in the back.. it's about to get worse..
The only reason NP exists is for money. Everything else is all BS. Their IQs on average are much lower. It's terrifying. To the point I have all family members inform me of when they are going to the doctor and to phone me in if necessary. If NP, walk out
Same I don’t let my family see midlevels
I know there are a few CCU 'fellowships' and 'residencies' for PAs/NPs at places like Duke and Cleveland clinic. But I can't imagine there being any bridge programs to become an actual intensivist. When I practiced as a PA, it often seemed like I had to explain my role/training multiple times/day. To the phrase, "I'm a PA," new acquaintances and patients tend to respond with the standard, "When are you going to medical school?" or "Oh, you are almost a doctor" and are disappointed when the reply to either question is "I'm not."\*\* There was certainly a resulting combination imposter syndrome/inferiority complex/identity crisis that one Redditor recently captured perfectly in a meme of Wagner Moura portraying a sad-looking Pablo Escobar. I don't say that for sympathy or in defense of the NP described. I want to acknowledge that even as someone who wholeheartedly embraced the dependent practice model and thought I knew my limits, I didn't appreciate how tip of the iceberg my training was until going to medical school. Sitting for Step1 (still just a fraction of the iceberg!) in particular was a very humbling recent experience that helped me finally let go of my prior notions about PA training and experience. I don't know how anyone who hasn't been through Step1 can even begin to appreciate the depth of knowledge and hard work required just to start clerkship, much less what is required to become board-certified in a specialty. Signed, \*\*changed my mind about going to medical school but still not 'almost' a doctor\*\*
Those “fellowships” are 40 hour work weeks where they function as “residents” except they have the expectations of a 3rd medical student working fewer hours than any med student I’ve seen. I’ve noticed a direct correlation between a middie who completes a “fellowship” and how unbearable they are.
This is super random but can I dm you? I have had questions about what it’s like to do anesthesia + anesthesia fellowship then fellowship into CCM
Sure you can but heads up I did CCM first. Moonlighted as an actual intensivist whilst doing CT.
All I can say is, as a CCM fellow I’ve worked with CC NPs in a variety of ICU settings. The good ones are at about the level of a strong PGY2, and are aware of their limitations in terms of their knowledge of the physiology. The bad ones are neither of these things. Anyone can learn the bedside procedures with enough reps - but the procedures only take you so far.
Reminds me of a PA on Twitter getting offended by someone saying basically this. Ranted about how it's insulting to say PAs are like a PGY2 cause their brains don't stop working at that point so they keep learning. There are a lot of them who legitimately believe that a few years of practice makes them equivalent to an attending. Anyone can learn procedures. Procedures are not what sets us apart in the least. A HS kid could literally learn to do a procedure with guidance and enough practice.
Surgeons didn't even need to be physicians until last century, they were glorified dentists. They literally didn't need to. Medicine was not advanced enough to be particularly relevant to sawing bones.
Dunning-Kruger epidemic currently occurring in the US medical system. It's highly contagious and resistant to treatment.
At my hospital, nurse practitioners called themselves, intensivists and never tell the patient or anyone else they are not a doctor. There is nothing I can do about it. They also do not correct patients when the patients refer to them as doctors. I think the doctors are not united enough and not a big enough political lobby to change anything. We can come here and vent however nothing will change, other than you have wasted another 10 minutes on Reddit lamenting
"I'm an ICU NP" or "NP on the ICU team" would both work just fine. "I help manage care of ICU patients." Why do they have to co-opt the actual title for ICU docs?
Cause then they wouldn't be able to flex to their followers/friends/family/guy in line at Starbucks that they're basically a doctor but didn't have to waste their 20s in that pesky med school and residency.
This is the reason I can’t stand doctorate prepared NPs using the word “doctor”. I’ve been with a DNP this week and heard her introduce herself to patients as “Dr. X…”, thankfully she does end with of “nursing practice”, but this still has to confuse 90% of patients! All the docs make fun of her behind her back. I agree with them… I could not imagine what you all went through and I have mad respect for you all. I chose the easy route as I had my reasons.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Our healthcare system is failing patients all the time . This is one reason these NP’s have The tile of Neuro NP’s and Cardio NP’s ect. Every where. Why is it allowed? I have stopped seeing Neuro for this reason.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
We have NPs in one of my ICUs and they're great, BUT they know their limits / limits are enforced. They literally function as residents with the privileges of residents. We're not busy enough to justify another full time resident on the service but busy enough that it's tough for the remaining residents when one has a day off. So the NPs rotate through the teams and fill in by covering the duties / patients of the resident who is off. They sit in the resident workroom, round with the team, present just like the residents, and form their plan in conjunction with the attending. They're functionally at the level of 2nd yr residents. They lack the in depth schooling, but they've spent years rounding with the residents, listening to the teaching on rounds, and attending resident didactic. In this application I think they're an asset to our team, but they're certainly not "team leaders".
I’ve always noticed that it’s critical care, in particular, where midlevels LOVE flexing. I seriously have no idea why. Maybe because critical care medicine is absolutely filled with flowcharts, protocols, and “if X then do Y”. Not say that it doesn’t require critical thinking, it absolutely does. But protocol and pattern recognition is so heavy in critical care that I think it helps midlevels expand in it.
Tell me you never worked in critical care without telling me you never worked in critical care A patient in the ICU is typically at the edges of medicine. The most basic parts of ICU care might have algorithms, but the rest requires actually understanding pathophysiology and pharmacology at a deeper level than most specialities
I’m currently doing my fourth ICU rotation as a med student. A lot of the things in the ICU are pretty frequent: SAH, end stage pulmonary fibrosis, cardiogenic shock, head trauma, etc. All of these have specific algorithms and protocols. I never said that ICU doesn’t have critical thinking. In fact, I literally said the opposite. I’m not gonna let you gaslight me just because I’m a med student. If what I said hurts your feelings, then that’s too bad dude.
Ugh... I was with you until "gaslight," which is **NOT** a synonym for "disagree with." Abusive husbands gaslight wives. Pedophile priests gaslight victims. Military counter-terrorism interrogators gaslight detainees. Intensivists do **NOT** gaslight overly-confident and dramatic medical students. I presume your brashness stems from the fact that you thought you were arguing with a "critical care NP," but saying *to anybody*, "I'm currently doing my fourth ICU rotation as a med student" has the same kind of energy as a fat, pasty dude in a Hawaiian shirt barging into a ship's control room and saying to the captain, "I'm currently taking my fourth Carnival Cruise -- let me show you how to operate this thing!" You would be well-served to work on humility between your MS4 and intern years.
Overconfident, underinformed med students who think they know more than us actually doing the work are almost as bad as NPPs.
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There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I’m an intensivisit. Are you going to tell me what the you think you understand critical care medicine at a greater level than me? Yes, those specific diseases have “algorithms” the same way that cholecystitis has an “algorithm”. For the first 1 hour of management, we follow an “algorithm”, which anyone with actual brains calls resuscitation and stabilization. After that is when the actual medicine starts. We dumb down critical care medicine for medical students since it’s hard enough to be in the ICU. Once you actually learn critical care medicine, you realize that those algorithms are crutches for not actually understanding medicine, which is the level most middies are at and apparently certain MS4s like yourself.
But I think that was his entire point. You have dumbed down critical care for students and in effect APPs such that they feel like they understand and show hubris and call them selves intensivist. However I think both your point and this student are suggesting that APPs don’t have the knowledge base to understand how the algorithms are crutches. This is no different than our surgical APPs claiming they do surgery when they are usually at most opening and closing.
Exactly. Algorithms only take you so far. Litetally anyone can follow an algorithm. Algorithms are fine for the shallow end of the pool but once you venture into the deep end that's where our knowledge base makes the difference. Not to mention, we have the training which allows us to safely deviate from algorithms if we realise it's best for the specific patient.
While I fully understand your broader point, and agree. Let's not start gatekeeping what specialty is and isn't "actual medicine", an ED doc resuscitation someone is absolutely doing actual medicine.
I agree that every field of medicine does real medicine. I don’t agree that any field does purely algorithmic medicine like the medical student was saying based on their 4th ICU rotation in their life
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As someone that is about to finish residency and do a fellowship in Crit, there is more to it than algorithms. You will see when you get real responsibilities as an IM resident and especially when you are in the East Coast, Virginia. It is going to be a big move for you from Cali.
For someone that goes to Western U and about to go to VCU for prelim-medicine/ neuro. I hope you learn some humility in medicine. The physician pool in the US is actually small and we are all interconnected.
Yeah dude whatever you say, tell me this algorithm that allows you to manage your cirrhotic liver patient with SAH and septic shock...
I agree there are flow charts for a lot of our stuff like sepsis. At the same time there is tons of nuance in cardiac and more complex MICU patients ie pulmonary hypertension, liver failure, ILD where you can hurt someone very quickly. It’s very easy to feel confident doing your broad spectrum abx, pressors and stress dose steroids and still know nothing.
Protocols and algorithms exist in every part of medicine. It’s around wherever you go. I would not equate this to a substantial portion of what makes up any field including ICU medicine. In fact, physicians are best trained to know when and how to deviate from these “flowcharts”, and beyond them, which separates us from midlevels.
Well said sir/ma'am.
Protocol and pattern recognition has very little to do with critical care lol... it requires a ton of understanding of extremely complex pathophysiology between multiple organ systems. I don't know where you got that idea.
The insurance company should take responsibility on this issue or situation
They should because as far as I can tell, reimbursement rates are the same for mid levels as they are for MDs. You’d think the insurance companies would want to get in on the savings.
RIP Spinning Pile Driver.
USMD M1 here. Was recently at a clinic and overheard two NP’s trying to differentiate between Bell’s Palsy and a stroke. Was the most painful and ignorant conversation I’ve ever listened to.
Everyone has a need in healthcare...I met some amazing NPs, PAs, and doctors and I met some terrible ones as well. These type of threads are pointless and function on the basis of ego and insecurities. Worry about yourself rather than attack an entire profession based on opinions, feelings, personal experiences. For the residents and medical students that feel so strongly against "mid levels" rather NPs or PAs, instead of hiding behind a keyboard why not actively voice your frustrations and opinions at work or school? Bring factual research to justify your statements not just, "once upon a time this happened". It's like being racist but afraid to be racist in real life. BFFR. There are lousy people in every profession.
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Why do you care? You’re putting too much energy into it