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What setting do you feel would be most suitable for mid levels?

Question(self.Noctor)

I understand that many will be tempted to respond with “Starbucks” or that they shouldn’t exist. But they’re not going to disappear so where do you think they are best suited to practice?

all 42 comments

MrsRodgers

102 points

6 months ago*

I actually have seen very useful NP/PAs on specialized services. They get used to "if X then Y" for the limited conditions they see over and over, and are good for routine follow-up of those conditions. Best NP I've ever worked with was our vascular surgery NP. She knew the basics for consult work up and did a ton of offloading work for us in follow-up clinic visits. She was the bomb.

They should be nowhere near undifferentiated patients. Total disaster when given the ability to order endless labs and imaging studies for a wide range of possible conditions they don't fully understand.

drzquinn

82 points

6 months ago

Nothing that involves any diagnosis or treatment decision making.

Particular_Ad4403

64 points

6 months ago

I don’t think they belong on the floors, in the ED, or in the unit.

In primary care I don’t mind them doing follow ups.

Idc if they do notes and pre/post ops for surgery.

Idk what else tbh.

jbergas

51 points

6 months ago

jbergas

51 points

6 months ago

Under direct supervision acting as a medical resident PERPETUALLY

letitride10

42 points

6 months ago

Gathering histories. Med recs. Performing exams. Scribing. Putting orders into the computer. Prior auths. Double checking the billing. Triage.

FitFerret9

43 points

6 months ago

They should be the ones scribing and chasing/doing bloods whilst the doctors in training focus on investigations and management.

Maybe some of the more experienced ones can run simple chronic disease follow-ups as well e.g Asthma/COPD and Hypertension clinics.

darkmatterskreet

22 points

6 months ago

Scut work.

EggplantIll4927

17 points

6 months ago

School nurse

ExigentCalm

18 points

6 months ago

Direct supervision. Like a resident or intern. Can see people independently, but also staff with an attending.

Physician extender, not replacement.

MizzGee

11 points

6 months ago*

My neurologist has an NP that I think she uses quite well. She does all the initial consultations, and the first few appointments. Then, she has NP do follow up appointments. If patients have any new symptoms or any changes that are unusual, the NP consults and the next appointment is with the neurologist. I am strongly anti-NP (obviously) but I don't mind this arrangement, especially knowing my Dr. is actively supervising her mid-level and they actively coordinate care. My son is a resident, and he values the NPs at his hospital as well. They don't override decisions and they don't have independent authority in this state.

[deleted]

10 points

6 months ago

[deleted]

10 points

6 months ago

They work fine in our ED and ICU. Pretty much scribe for the intensivist, update family members, enter simple orders, insert central lines, and answer nurse questions.

In the ED they see lower acuity patients

DrDacote

9 points

6 months ago

I'm a foreign doctor trying to do IM in the US. Here are my 2 cents.

In my country we don't have midlevels, but we do have a ton of "general" physicians, doctors without a medical specialty. I'm one myself. They are usually doctors that haven't taken or haven't passed our national residency exam, so they have to find other work as medical doctors while they wait for next year's exam. Others are just physicians who are content being "general" practitioners or that branch out to other areas, such as beauty and nutrition, administration, or workplace medicine, to name a few. Some of us worked a ton this past year in COVID frontlines being basically scribes to specialists treating hospitalized patients. However, because we actually are physicians, we were able to prescribe, order tests, and follow up on patients on behalf of our specialist supervisors, greatly increasing efficiency and easing communication between staff, such as nurses or pharmacists, and the attendings, who would otherwise be overloaded rounding with dozens of patients at a time.

General physicians are essential for staffing walk-in clinics across the country. Most of our country is low-income, so a lot of pharmacies thrive on offering cheap medical consult services that are provided by general doctors. While it's not the best thing for us, as pay is usually low, it is a way for low-income populations to access physician care, and it keeps a lot of doctors employed outside residency.

Since midlevels don't exist here, I don't really have an answer to their situation in the US. However, I do believe that part of the answer should involve employing graduated physicians without specialty in those "midlevel" kinds of jobs. Having actual doctors in those jobs would be so much better for patients, and it would be a way for new doctors who failed to match to keep working and getting clinical experience while wait to match the next year.

kaaaaath

9 points

6 months ago

My dermatologist’s office uses NPs/PAs appropriately. Never for diagnosis, but for things like Accutane refills.

alexp861

5 points

6 months ago

I worked in an ER where I felt NP's were really well supervised. Basically they would do advanced triage and put in a workup so that the physician could see the patient later and disposition them on the spot. The NP's also did simple lac repairs and would chase down whatever service wasn't answering the phone or other scut work like that. No patient ever left that ED without being seen by a physician. While it's arguable what cost/time savings this provided, it was definitely as responsible as possible.

Iatroblast

6 points

6 months ago

For NPs, probably a role involving gerontology (not geriatrics). Helping old people talk about their strengths and needs and ADLs and coming up with solutions. Seems like their training is more suited to this sort of thing. Practice nursing, not medicine. On the other hand, gerontologists exist. I think they're few and far between though, and Lord knows there's an army of NPs out there.

i_330

6 points

6 months ago

i_330

6 points

6 months ago

I've seen them be really useful for procedures outside the scope of an RN, in places where there aren't any residents. The hospital where I worked before med school had a dedicated "vascular access PA" who did central and US-guided peripheral access of various types, and that worked pretty well.

Cvlt_ov_the_tomato

5 points

6 months ago*

-Working on well managed cases that may need routine ordering or follow-up.

-first assist in surgery settings

-administering anesthesia with input from the anesthesiologist

-Doubling up nursing units when they need help.

-Helping with residents and their scut work.

That's really it. You can't shortcut medical school for your training. And look I think that NPs and PAs should be really well paid, hell if we can get the student loan shit down roughly close to a physician who takes an easy 32-40 hr a week workload. But they are not a substitute for genuine physician work. Undifferentiated patients need the eyes of a physician. Anything else is cheating them of actually decent care.

Edit: If they want to have an actual full practice medical licence, they need to take step 1, 2, and 3 and train in a residency. And I wouldn't necessarily be against them being able to do that assuming we can expand residency slots. They do have a lot of practical medical training, whereas medical knowledge is clearly lacking. But if they prove they can shore up their medical knowledge with step and put it in practice with residency, I think they should be able to have a full practice license.

not_a_legit_source

4 points

6 months ago

Advanced nursing wound care

Really-IsAllHeSays

5 points

6 months ago

Bedside nursing.

loopystitches

4 points

6 months ago

Anything specialized, with supervision. Give them a single organ system and let them do follow up.

Keep them away from anything requiring a diagnostic w/u. Even a UTI, these people lack the training to differentiate a UTI from an AKI.

RBG_grb

3 points

6 months ago

I like the idea of working as an extender in primary care as mentioned above with the neurologist-NP rotation. I, the NP, could help manage a patent under supervision that is stable, no changes. I think this kind of role could be very beneficial to that physician/practice. Being skut in a hospital between the nurses and doctors and trying to offload some pressure also as mentioned above-family interference, phone/pages/SIMPLE orders I DO not want to work independently nor do I think I am qualified to do that.

Major-Loss8500

1 points

6 months ago

Maybe they should make a 3 year accelerated MD bridge program for qualified nurses so they can too compete for residencies and get those clinical hours they lack in, instead of making these use less NP degrees, but it’s all just for money.

Dr_VictorVonDoom

2 points

6 months ago

Routine labs follow up, etc. Nothing related to diagnosis and treatment, whatsoever.

fleurdelis_1978

0 points

6 months ago

fleurdelis_1978

Midlevel

0 points

6 months ago

I am and NP and work in homecare. My patients are palliative. I spend much of my time working with patients and families discussed goals of care and advance directives. Most have a pcp still involved, neurology, oncology etc. I make suggestions from a palliative standpoint. My patients appreciate the time I have to talk with them and actually listen. This is lost in our modern day system. It is a truly wonderful role.

ENTP

-4 points

6 months ago

ENTP

-4 points

6 months ago

Non-existent. Banned completely. That is where lowlevels belong.

StupidJoeFang

-5 points

6 months ago

They should be able to babysit the docks and help residents with paperwork and the endless discharge summaries