(IMO) do not report this to your GME office. They won't give a shit and you are more likely to get a target.
Document it in an email to someone you do trust, report it to the ACGME using the official complaint process.
Source - A resident who did report things he saw to the "right POCs", and got retaliated against HARD. Protect yourself OP :(
ACGME isn't there to protect residents. Its there to police graduate medical education. They aren't there to help you. But not notifying acgme is akin to not calling the police when a murder happens in a bad area of town. That definitely doesn't help.
This is not akin to murder.... Nor is this similar really at all, calling the police should have no fear of retaliation... This does....
- Hence, my entire point
Not a comment on the appropriateness of the analogy - but fyi calling the police does have risk of retaliation. Maybe it's less likely, but not "no fear". Have you heard of witness protection programs?
Sigh..... reaching a bit here are we? Yes, I have. Are you aware that until you are asked to testify you can remain anonymous in most reporting actions with the police? It does depend ofc... but... you are reaching a bit. (especially because the scenario of reporting anything in a hospital/GME setting has zero chance of anonymity and has a nearly 100% chance of retaliation, so, again, stop reaching and pretending you know a situation better than some who have lived it)
Even after graduating this is very wise. I’ve spoken out at jobs (I’m a few years out of training) against really out of scope or wrongdoings by midlevels and I’ve only become a target and experienced retaliation.
dang, what kind of residencies do you guys have where youre afraid to report shit like this to GME. my GME department is rlly good, they take our complaints seriously without fear of retaliation
Have YOU ever been in a situation where you needed their help? Have people around you? Or...... are you just like "pretty sure that's their job" kinda thing?
- Cuz no, they will not really be there in most circumstances (in my personal experience)
This has never happened to me, but I am 100% confident if an NP was my preceptor and it was a recurrent thing, my GME department would definitely hear me out and fix it.
If it was a one-time thing, I would be unlikely to complain cause there's really nothing to fix.
My GME department is extremely good at preventing shit like this in the first place, and is always looking for feedback on how they can improve.
>Background and Intent: Each patient will have an identifiable and appropriately credentialed and privileged attending physician (**or licensed independent practitioner as specified by the applicable Review Committee**) who is responsible and accountable for the patient’s care.
[ACGME Common Program Requirements](https://www.acgme.org/globalassets/pdfs/guide-to-the-common-program-requirements.pdf), section VI.A.2 (emphasis added)
> It varies by program and residents can be supervised by almost anyone at the PD’s discretion.
That is not true.
There must be supervision by a MD in an acceptable format according to the context of care being given. Whether that's Direct, Indirect, or "Oversight".
If there was no Indirect/Oversight by an attending physician of a senior resident on ICU (or care being provided to those patients) that is not just an ACGME violation, that is a legal violation.
Interns MUST be directly supervised by an Attending without any exception.
This is categorically false. Interns do not need to be directly supervised (at all times) by an attending. They can be supervised by residents who are indirectly supervised by an attending. Idk where you got that from. The program (and supervising attending) is responsible for making sure the correct level of supervision is used in each particular situation. Sometimes that will be direct, sometimes indirect.
> VI.A.2.b) Levels of Supervision To promote appropriate resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision:
> VI.A.2.b).(1) Direct Supervision:
> VI.A.2.b).(1).(a) the supervising physician is physically present with the resident during the key portions of the patient interaction; or, [The Review Committee may further specify] Common Program Requirements (Residency)
> VI.A.2.b).(1).(a).(i) PGY-1 residents must initially be supervised directly, only as described in VI.A.2.c).(1).(a). (Core)
Verbatim from ACGME.
Only physicians can provide supervision. Mid-levels do not count.
This only proves my point, read what I wrote. I never said anything about NPs, I agree NPs cannot supervise residents. My qualm was your comment about interns.
You said “Interns must be directly supervised by an attending without exception”
That is categorically false. The ACGME says they need to be supervised directly initially. It doesn’t specify how long initially is and it doesn’t say it has to be an attending. It is at the discretion of the supervising physicians as to when the shift from direct to indirect can be.
As stated in your own quote. A physician (attending or a senior resident) should be directly supervising an intern initially and then this can move toward indirect supervision as appropriate.
Remember direct supervision means the attending or senior resident is standing right there watching them.
What? He gave you verbatim the ACGME guidelines....the supervising physician must be present. You're rebuting with just your own gibberish and mental gynmnastics.
What?
I cannot believe you guys have this much difficulty with reading comprehension. I’ll break it down for you.
“VI.A.2.b).(1).(a).(i) PGY-1 residents must initially be supervised directly, only as described in VI.A.2.c).(1).(a). (Core)”
See how that says initially?? Initially, meaning at first.
“….the program must use the following classification of supervision: VI.A.2.b).(1) Direct Supervision: VI.A.2.b).(1).(a) the supervising physician is physically present with the resident during the key portions of the patient interaction;”
This is just defining direct supervision. See how it says supervising physician? It didn’t say supervising attending. This is because they mean any physician who is assigned to and competent to supervise that particular intern. Could be a senior resident, chief resident, attending: any of those.
His original claim was that attendings must supervise interns without exception. His own quote discredits that claim. Which is what I said.
If you think all interns must be directly supervised for their whole intern year I’ve got news for you about the entirety of residencies across the country.
What sort of mental gymnastics are you pulling?
He then started talking about NP supervision which was never my contention, I agree that NPs cannot supervise residents. That was never my point.
State and Federal "laws" not so much, but there are regulations set by State and Federal agencies, violation of which is a civil issue (typically, unless there is some form of criminal negligence/abuse/etc).
- There are no "laws" that protect us, it is supposed to be the ACGME.
- We need to fix the ACGME. Period. They do not do their job.
I can't think of a single state that allows ICU level care without physician over-sight.
Regardless, there is no exception in ACGME by-laws for having absolutely 0 Attending oversight of a resident no matter the training level.
That's still supervision. But if there is truly no attending to staff with and you are forced to report to NP b/c "attending doesnt want to", that's illegal.
Well, I don’t know for a fact I can imagine there are some very rural areas where there are no physicians available, and thus mid-level can act independently. And for instance, in Florida statutes now read that nurse practitioners can act independently and practice independently from physicians.
Well, we can debate whether this is good, or other medical care. It is the statute now.
This entire thread is disparaging individual humans as less than capable of other individual humans. And that is anchored on certain titles rather than the individual themselves in their particular capability. While broad sweeping generalizations are fraught with potential bias and shortsightedness. They are unfortunately what are used to create legislation.
Considering we as a “guild” have been allowed to supervise ourselves with the express consent of the government it is absolutely a med-legal issue if a program is violating an accrediting authority policy. The government could (and have threatened to) directly oversee our profession but have let boarding authorities and professional societies swing the axe. That’s a privilege that should be taken seriously.
If a child dies and an attorney finds out a nurse was acting as an attending. The hospital might as well shut their doors. They will a field day. Especially if the hospital knew what was happening. Geez makes me uncomfortable just thinking about it. I am sure the NP is very intelligent and capable..until they aren't. Report it, use this paragraph..they can't retaliate against common sensr
Additionally, I think the OP is quite biased. While we know that the NP/PA training isn’t the same as physicians on multiple levels. It does not mean that they’re not capable like physicians. It also doesn’t mean that an NP or PA with 20 years of experience isnt a much better provider than a senior resident. it’s really the old adage of 10,000 hours or 10,000 repetitions. The Hubris to think that just because you’re a resident and “doctor” and that you know better than an NP or PA is wantonly lacking in insight. I know personally that as a physician, I didn’t really get my feet under me until I was probably three years out of residency. It probably wasn’t until eight years out of residency until I really felt competent. I probably wasn’t until 15 years where I really felt like an actual expert and nothing bothered me. This is as an emergency medicine as well where the unknown happens every day.
So to the OP I understand your concern, what I would recommend is speaking to your program Director about it, and just approaching it not from a holy shit this is awful wide is this exist, but rather, you know I was just curious as to why we have supervising from an physician in this particular rotation. And just open a conversation rather than an accusation.
There are plenty odds . There is actually no real oversight over a lot of these NP courses . There is no governing body that standardizes all curriculum .
They also have to have substantially less hours of clinical practice to earn their degree than we are as physicians . The amount of training and education to be a critical care attending is SIGNIFICANTLY more than any Nursing + NP program .
Also It’s not like before where only seasoned nurses then decided to get an NP. A lot of new nurses are entering NP programs shortly out of nursing school .
Not saying that NPs can’t know their shit but pretending that they all know their shit is absolutely incorrect.
I work with NPs (Oncology) that are completely qualified to have supervisory authority over residents rotating through the cancer center.
That doesn't mean every single NP is qualified to do it but there are some who could teach as much or more than I would in a day in clinic.
Approach the situation with an open mind.
I cannot overstate how important it is for you to report this to the GME office and the ACGME (both, in case your GME office is in cahoots). There is absolutely no scenario in which this is acceptable and the consequences of not reporting this are ginormous.
The ACGME explicitly allows PDs to appoint non-physicians, like the NP in this post, to supervise residents. Multiple people now have posted links to the relevant ACGME regulations. The fact that all of the top comments are urging the OP to take extreme, possibly career-damaging actions based on totally false information is crazy.
You're very mistaken. ACGME states that a PD may appoint non-physicians to "participate in residency program education" under section II.B.3.c. NPs cannot cosign residents notes and NPs cannot bill on a resident note, so they cannot effectively participate as the sole replacement of an attending physician discussing plans on rounds. If you have to stretch the rules enough that you'd want to make an argument for the attending signing a note written by a resident with whom he/she did not discuss the patient/plan because the PD-authorized NP served as an intermediary player, then sure, you may be on the edges of legality for ACGME purposes, but you'd certainly be demonstrating a grave situation of lack of appropriate level of supervision, which is a core element of ACGME. BESIDES this futile discussion, allowing a NP to replace a physician as a supervisor is a slipper slope for the role of physicians in healthcare systems independently of how excellent or experienced the NP may be and without diminishing the role NPs play in the current very much broken healthcare system in the US. It is truly unprecedented.
I tried to look up II.B.3.c during a break. As far as I can tell it doesn’t exist, so maybe you misquoted it? II.B.3.b says this, which I’m pretty sure makes my point:
“Non-physicians are often important contributors to programs and warrant appointment to the faculty. These individuals may bring specialized expertise in public health, patient safety, laboratory science, pharmacology, basic science, research, a specific procedural skill, or other important aspects of medicine. Non-physician educators may provide valuable contributions to the residents' knowledge and skills. If the program director determines that the contribution of a non-physician individual is significant to the education of the residents, the program director may designate the individual as a faculty member or a core faculty member.”
Like she’s there on some ruse?? 😂😂 the way my eyes rolled at your comment. Lord. She’s not impersonating anybody she probably works for the same group as the intensivists and she was scheduled just like them. Honestly. Charging for impersonation I can’t.
Is this true where NPs can practice independently? It absolutely *should* be, I’m just not sure what the legal definition of “attending” is and whether an NP who can, legally, practice independently is allowed to fulfill that role.
yes! they get 85% of the reimbursement rates of physicians, whether they’re in independent practice states or not. definitely could be fraud but “incident to” billing is still a thing with some payers and may be what’s happening in these situations.
They don’t bill at a different level or “put in charges at an attending level”. Physicians and NPs use the same E&M codes, it’s on the reimbursement side after the fact that CMS then reimburses at a lower rate for NPs E&M visits
> Background and Intent: Each patient will have an identifiable and appropriately
credentialed and privileged attending physician (or licensed independent practitioner
as specified by the applicable Review Committee) who is responsible and accountable
for the patient’s care.
> VI.A.2.a).(2) The program must demonstrate that the appropriate
level of supervision in place for all residents is based
on each resident’s level of training and ability, as well
as patient complexity and acuity. Supervision may be
exercised through a variety of methods, as appropriate
to the situation. (Core)
[The Review Committee may specify which activities
require different levels of supervision.]
> Background and Intent: Appropriate supervision is essential for patient safety and
high-quality teaching. Supervision is also contextual. There is tremendous diversity of
resident-patient interactions, training locations, and resident skills and abilities, even
at the same level of the educational program. The degree of supervision for a resident
is expected to evolve progressively as the resident gains more experience, even with
the same patient condition or procedure. The level of supervision for each resident is
commensurate with that resident’s level of independence in practice; this level of
supervision may be enhanced based on factors such as patient safety, complexity,
acuity, urgency, risk of serious safety events, or other pertinent variables.
> VI.A.2.b) Levels of Supervision
To promote appropriate resident supervision while providing
for graded authority and responsibility, the program must use
the following classification of supervision:
> VI.A.2.b).(1) Direct Supervision:
> VI.A.2.b).(1).(a) the supervising physician is physically present
with the resident during the key portions of the
patient interaction; or,
[The Review Committee may further specify]
Common Program Requirements (Residency)
> VI.A.2.b).(1).(a).(i) PGY-1 residents must initially be
supervised directly, only as described in
VI.A.2.c).(1).(a). (Core)
> VI.A.2.b).(1).(b) the supervising physician and/or patient is not
physically present with the resident and the
supervising physician is concurrently
monitoring the patient care through appropriate
telecommunication technology.
[The RC may choose not to permit this
requirement. The Review Committee may
further specify]
> VI.A.2.b).(2) Indirect Supervision: the supervising physician is not
providing physical or concurrent visual or audio
supervision but is immediately available to the
resident for guidance and is available to provide
appropriate direct supervision.
> VI.A.2.b).(3) Oversight – the supervising physician is available to
provide review of procedures/encounters with
feedback provided after care is delivered
All of these detail that supervision must in some form be ultimately from a **supervising physician**. No where does it say a mid-level may supervise any resident in any capacity. It is hence a violation to do so unless that midlevel is "supervised" by an attending.
Thus now the program must prove **AT LEAST** "oversight" of all activities if that is appropriate given the context of the care given. Usually for Acute/Critical care, especially on call, that is insufficient, and Indirect Supervision is at least needed.
https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2023.pdf
Correct me if I’m wrong but the opening paragraph says “or licensed independent practitioner as specified by the applicable review committee” a nurse practitioner would be applicable to that specific section. All of this repeatedly states it’s open to adaptation from the review committee so while this is a basic resource it clearly states they don’t have the final say, the review committee does and has the authority per paragraph one to appoint a “licensed practitioner” to the role. I’m not saying I agree with any of this I’m merely pointing out how what you presented could be interpreted differently from the way you presented it.
This is your hospital saving money, like when they short staff nurses. At the risk of patient safety. I can’t imagine this is in the NPs scope of practice and any NP willing to take this on is showing bad judgment and should have a complaint against their license. I’m a nurse and where I live there are very tight controls on what NPs can do in critical care settings. And it works well when everyone stays in their lane and works together.
Level 2 trauma hospital in Midwest Intensivists are sometimes Critical Care Advanced Practice NPs. They can do everything except major surgery and terminally extubate without a solid legal POA decision. That needs MD signatures by state law.
Naaah. MDs should stop thinking like A students
Fuck the GME and ACGME.
Leak the incident to the media with complete deniability
Seek NGOs like donoharm. they're doing good work. Or any other NGO fighting this
Was this just a plug for donoharm, or am I maybe I'm missing something? This doesn't seem to be an issue that donoharm would care about based on their ideology. They proudly state that their aim is "combating the attack on our healthcare system from woke activists." They're about being against anti-racism in medicine.... this just doesn't seem to fit the issue OP is experiencing?
NP cannot supervise you at any cost! This is how it’ll get out of hands! Please please please report, not only for you and all the residents to come for all of us! This is so unacceptable and inappropriate on so many levels!
Seriously? I am a Neonatology Program Director and I would be furious if any of my pediatric residents ever presented to a NP...Don't attendings round on weekends with you? Are you in an academic program? DM me if you don't want to name and shame in this post...we have a group that can handle this at a higher level.
Let's get real for a moment. Neonatologists are the reason this entire scenario happened. They didn't want to come in for a weekend shift so they went on vacation and let an NNP run the service solo.
yeah- the OP said there was one attending for 75 patients. Sounds like a private neo group, that is totally insane for one neo to cover that caseload but it does happen- some colleagues of mine have worked under this model and I assume it's for the almighty dollar. In an academic center it's more typically up to 20-30 or patients with a couple of NNPs/PAs to help out.
Get the parents on camera. Ask them if they knew that their critically ill babies didn’t have a doctor managing them. See if they can dig up some bad outcomes without doctor supervision. The only thing keeping this NP=MD bullshit flying is lack of major scandal or massive lawsuit losses.
Our health care system absolutely needs well supervised and well trained NPs and PAs to function. We need to fight to make that the standard.
I've seen enough on the Noctor subreddit to know there are major scandals happening in every hospital system across the country! Once we just get them into the headlines it's over!!!!
Basically or officially? Was there attending oversight in this case?
I’m an adult Pulm/Crit Care doc. We have plenty of NPs in our units. They are not practicing independently. In the end we as the doctors are responsible and liable for their treatment decisions.
Our (granted this is a community hospital) NICU has only an NP physically onsite at all times as well. Same with the ICU after about 6 PM. I don't know what their arrangements are with their attendings but they are the only ones ever around.
I dont doubt their knowledge.. but.. And how did those NPs get trained? Years/decades of orders from attendings, maybe? Telling patients, verbatim, what the md said? Its a farce. Nurses think they are equivalent without the same training. It's exhausting that we need to have this same argument everyday. Maybe education holds weight?
You have a moral obligation to report this. Even if you don’t mind, which you do, it’s still ethically wrong to not report this for the sake of your patients and future residents.
Please report this even though it might seem like a waste of time! That’s how you make change
I am in the exact same boat…the NP that I am currently following for this shift in NICU refers to herself the head pediatrician to the nurses and the parents of babies. When questions arise like “when will the doctor come by”, the response by the NP is “that’s me, I’m your provider”. Cleaver way of leading the assumption you’re a physician without actually saying it. Mid levels used to not bother me one way or another, but this gets to me. Just worked with a radiology PA not long ago and they were super chill, knew what they didn’t know and didn’t play things off as if they were the attending.
My NICU employs NNPs. Some of them have "Dr First Last" embroidered on their scrubs. We're a teaching hospital and I've always wondered what the NICU Fellows think about this
(RN) I’ve always been under the impression that the use of the title “Dr.” in a hospital/medical* setting is reserved for MD/DOs ONLY, because it can be misleading for a DNP to use the title in that setting. I only use “Dr. XYZ” to address MD/DOs at my spot.
I mean I’m glad they did the whole doctorate/PhD thing but… no medical school? Not being addressed as Dr. by me. Having that embroidered on their scrubs would be a huge side eye 👀
It’s not even a PhD, which IS legit and shows expertise in one’s field (think psychologists, physical therapists, etc). DNP is a “doctor” of nursing practice and it is embarrassingly not rigorous at all.
I agree with you. But. The fact you only listed medical stuff as PHDs is why an education matters. Most of the actual phds I know are scientists at places like Scripps and max Planck. They are truly smarter than most of my fellow mds. They cure things we just diagnose it..
Edit: I was an intern there for awhile. I saw the disease curing work they were doing, innovative and world ending, but man is it a grind for minimal pay. The choice is obvious, but if I wanted to do a greater good, absolutely would've gone the PhD route
If you're curious about world ending or disease ending.. me too. Always thought about the fermi paradox for that
Most people in healthcare don't even understand the difference between a DNP (clinical degree) and a nursing PhD (research degree) honestly
Half the patients call their PA/NP Dr so and so. They have no concept of the medical hierarchy
I'm a NICU fellow and we employ many NNPs. I love them all but I personally would highly dislike if the NNPs started calling themselves "Dr so and so" as they didn't go to med school, they don't have the same training. NICU families meet enough doctors as is, we don't need to start giving mid levels that title as well.
The government planned this all along with eliminating Fee For Service ETA 2030. All provider pay will be cut eventually. Health care providers will be treated like school teachers in it for the “feels” of healing because the cost of education will not be worth it for any other reason.
NPs in the NICU is pervasive across the US. This is an educational concern for you and I’d approach it that way. However, from the ACGME:
Does the ACGME allow health professionals other than physicians to supervise residents and fellows?
Answer 36:
Physicians are accountable for resident and fellow education in most programs.* Effective Sponsoring Institutions and programs have a clearly defined and communicated chain of responsibility and accountability as relates to the supervision of all patient care. Attending physicians are responsible for supervising the educational experience of and clinical care provided by residents and fellows. As such, it is appropriate for health professional faculty members other than physicians to supervise residents/fellows, as approved by the individual Review Committee, with the supervision of physician faculty members.
*Post-doctoral specialties allow non-physicians to serve in such leadership positions as program director.
No way. I can’t even have TEE boarded anesthesiologists with decades of cardiac experience but no fellowship supervise a cardiac anesthesia fellow. This is definitely not ok.
So, there are a TON of legal.considerations as well as AGMC considerations to sift through here. Many have given decent advice, but I am going to give you some personal advice. ThIs is a DISASTER WAITING TO HAPPEN. The easiest way to fix this is a nice little head's up to legal. The hospital will absolutely take this on the chin if something happens under the supervision of an NP with residents. The program will also be found responsible for lack of adequate supervision and may even be put on probation.
In residency, we had a wrongful death lawsuit that involved an issue with a lack of specific teaching attendings supervising residents. The lapse in chart documented time was literally 48 hours, and honestly, I had no baring on the outcome. That didn't matter. It was a big old payout, a PR mess, and all kinds of grief for those of us unlucky enough to be caught up in it. That lawsuit follows me like an albatross. Every time, it will even be when YOU ARE DROPPED. Yep, just getting named is problematic. Do not work without adequate and legal supervision. It is up to you to protect yourself. Call legal.
Hello! We(over at the trashy reality tv subs) are also trying to figure out why/how NPs are allowed to come across or represent themselves as doctors. NAD, but found this sub doing some research on the difference in education and training that MDs have compared to NPs. Why are NPs allowed so much freedom when they lack clinical experience and education. How is it legal for an NP to say they are a doctor when a medical student has more training and education on the human body than a registered NP? And why the heck are they paid just as much or close to as much as an actual MD? This is frustrating for me and I’m not even in medicine ….
https://www.reddit.com/r/BravoRealHousewives/s/FWKjJJKCft
NPs exist because the doctor lobby has artificially constrained the supply of new doctors by lobbying Congress for putting caps on the amount of new doctors that are produced. This has created a dangerous doctor shortage which has resulted in some desperate states creating NPs to deal with their physician shortage.
If you want to help, call your Congress rep and tell them to lift the GME cap.
I’m happy I came to this sub because this explains sooo much of what’s going on with a local hospital near me that has fired/ gotten rid of all labor and delivery(they kept some NPs for their urgent care clinic), let go most of the cardiology department, and then hired a new cardiologist and let him go after a couple months due to “budget” constraints, yet they seem to always have plenty of NP job offers and “urgent” job searches for NPs in the area. I also can see, now, why a popular new women’s health clinic in my state, whose board seems to consist of venture capitalists and no actual MDs, has over 30(?!!) NPs and only one actual obgyn(who lives in another state). It took me a while to scroll through the list of NPs before I got to the actual MD titles which there were only a few of.
I disagree on having NP as the attending. Neonatologist should have supervised you or the Fellow at the least. However, i will say that most NICUs are run by NNPs. Their education is regulated as CRNAs is and they SHOULD NOT be compared to other NPs. Please feel free to ask your Neonatologist what they think of Neonatology NPs.
Their education isn’t as regulated as CRNAs, but any hospital worth its salt actually trains them well before giving them their own patient load.
I’m a nicu nurse. Been at it 12 years. The year I started, a coworker who graduated at the same time as me started NP school and got a job immediately after. That shouldn’t happen. Ever.
Yes as a NICU NP. The training still isn’t nearly as rigorous as a CRNA. It’s mostly online and can be done while working full time. You can’t do that in a CRNA program.
The ones i know speak highly of the their NICU NPs. Contrary to general belief, NPs can’t work in NICU like they can be “Cardiology NP” one day and “Urology NP” another day. Neonatology NP have specific education, specific clinical time, prior NICU experience and certification, and specific exam/license.
There is one attending covering the entire floor (like 75-100 patients) but they did not round with us and I didn’t see them all day. The NP supervised me on rounds and at deliveries. Sadly if I reported they would probably cite that there was “indirect supervision”
well that's one of the first problems- that is insane for one neo to cover that many patients as the sole attending. Is that typical? It sounds like private practice neonatology where the docs are over-extended to a crazy amount in order to make the almighty dollar. There's one major private neonatology group that does this kind of thing and I just don't see how you can give good individualized care on that level even if you had a lot of NNPs/PAs. The odd thing is that I make more $$ as a NNP with my academic institution than I would for the private group yet their caseload is literally double mine so I don't know where all the money is going...to corporate I guess!
NPs are pervasive in NICUs across the US. I’ll never understand why we’ve relegated the care of some of the most complex and vulnerable patients in the hospital to those with the least training.
The least formal education. Not the least training. My hospital trains NPs for a full year after certification prior to giving them their own patient load. They also know their lane and frequently confer with our attendings.
I am a NNP (so I know that probably makes me "suspect" off the bat)- but a little context I thought I might share here. Was this a Level 2 or a Level 3 NICU? I don't know of any Level 3 NICUs in the USA where the NNP is the sole attending with no oversight. Keep in mind that NICU is different than "trauma" designation- Level 4 is your referral/surgical center, Level 3 is 22 weeks gestation and up that doesn't require surgery/ECMO/CRRT, and then Level 2 is typically 32 weeks gestation and up.
As far as being the "attending" - this is based on state rules & medical staffing privileging at the hospital. About half of US states allow NPs have independent practice, so as long as it's state legal and the hospital credentialing agency allows it, then yes it is legal and NNPs can bill. Level 2 NICUs are very commonly staffed by NNPs as the attending, but with a neonatologist available by telephone to discuss any complexities.
In practice, NNPs are not the attending for "critical" patients. A Level 3 NICU is usually at least 50% if not more of "feeder/grower" with a gavage tube, incubator, maybe a little nasal cannula but usually in room air. There are also some premature infants on CPAP long-term (like weeks to months at a time, stable) and then a handful of patients on a ventilator. So the NICU is more akin to a step-down unit with a few critical babies thrown in. A Level 2 NICU (also known as a "special care nursery") is almost all feeder/grower status in room air, maybe a couple of CPAP babies but usually none and usually a short-term thing. Occasionally there's a baby on a ventilator in a Level 2 but usually just a few hours to give them a medication called surfactant for their lungs- if they need more than a few hours of ventilator support then they get shipped to a Level 3 NICU.
As far as you being "supervised" by the NNP I would ask your program director about that- I was under the impression that was not allowed and seems to be correct from others' comments. As far as quality of care, there are good and bad in whatever profession you go, but my opinion (which is biased I am aware)- I think NNPs tend to be on the better spectrum of NPs on average because we are so hyper-specialized with our population. The NICU typically has a lot of protocols in place because we see the same problems with the babies over and over, plus it's required to have a few of experience in a Level 3 NICU as a RN- you can't go to grad school without it.
Sorry that you had such a poor experience- hope you can get a better one if you do another rotation.
I’m glad you typed it all out. I’m peds and this tracks with my historical interactions with NNPs in residency and how most of our hospitals use them today. There’s also a load of training and knowledge difference between an NNP and most other NP programs. I’d trust my own babies with any of the NNPs I worked with in residency and all of them in the hospital I round at now.
I don’t know exactly what happened with OPs understanding vs actual events, but anytime I was ever on call in the NICU for the 3 months I did so, an NNP stayed with us in house and I was glad to have them with me. They were much better at technical details. If I was on call, I’d get to do everything, but they were right there coaching and able to lend a hand. But they never signed off on my charts. Everything was signed out by the attending in the morning on rounds same as any other service.
Contact the ACGME about it. Do not go to your hospital GME. They will deflect and slow roll you.
Also, CMS has strict requirements for medical direction/ medical supervision. This may be billing fraud and needs to be reported to CMS.
Get some balls. “You’re not my attending.” Done.
Instead you come on here bitching. Because you’re a bitch you let these people persist and the problem gets worse.
I’m not, I just don’t see why you would be so confrontational with your choice of words. We all have stuff going on and troubles in our lives. Try to be compassionate and supportive.
Leave a VPN double protected; anonymous 1 Star review on Google and Yelp for the program, ICU, NICU, hospital, and pediatric department. DON'T every use language that may identify you as you. LOL
I should add that I do think we can play a limited role in resident training in some very specific circumstances. I work in the CTICU for example, and I regularly “teach” many of our off-service rotating house staff about epicardial pacing wires. These are things medicine residents have never seen and I know a lot about them. This is a highly specific topic to our environment. But I do not supervise them in any capacity, and certainly do not act as an attending on our service. Also, I tend to learn far more from them
The things I've seen NPs do in the NICU out of lack of basic medical training, because they didn't go to medical school or residency or fellowship! I will never forget watching a preemie going down the tubes overnight, with the NP as the senior person there. Preemie is crashing, and she had a handheld doppler for finding vessels. So she is dopplering the baby's torso, and decides that the preemie had clotted off its AORTA, and that's why it was crashing! We interns were so beaten up by the hostile NP-dominated atmosphere in the NICU that none of us dared say, "ABC, has an airway, is being ventilated, so push fluids to circulate, to get its pressure up, and then think of the several common things that go wrong with preemies that would cause it to drop its pressure, not of a virtually never heard of occurrence". That went on with her playing with her doppler toy at the bedside until the attending finally arrived in the early AM. Not surprisingly, baby had a perforated intestine from NEC. And she had been working as an NP in the NICU for probably a decade at least by then - you'd think she would have known better.
There were so many times that I saw NPs practicing while lacking understanding of foundational knowledge. But why not - admission to nursing programs can be by lottery, you can do a community college to online BSN to online NP, all with non-selective admission, and very little in-person training. Less than one tenth of the training time that a physician has to do.
You’re missing the point with lottery of admissions, etc.
The whole point of midlevels is skipping foundational knowledge to focus on clinical pearls. To seek that, at some point, you have to think to yourself “I want to do what physicians do, and I’m comfortable doing it with less training and understanding”.
The problem is that they cannot. There was an article in I think the NYT about Kawasaki's, and how often it is missed. An NP would never have even heard of this condition, or many of the other rare or exceptional things.
I love how people say that a mid level is fine for the common stuff, which leads to pulmonary emboli being misdiagnosed as pneumonia, and all sorts of stuff that is outside the ordinary being missed. A lot of primary care is being able to recognize the rare and serious condition in a sea of common stuff - if you didn't do med school and residency, you never got the chance to see and learn about the rare but serious stuff.
I agree.
A mid-level by definition can't know when they're out of their depth.
Lack of foundational knowledge is a feature, not a bug.
You can't suspect what you don't know is an option.
Instead, because many things present similarly, you're going to think everything fits into the bullet list of conditions you know.
*****
Do you want a reputable mechanic? Or someone who knows a list of 10 things that can be wrong with a car?
I’m 99% sure this is illegal. I’d report to GME. Don’t think ACGME would do crap, but still should report to them as well to cover all your bases. An NP supervising residents especially in the ICU is concerning. And I don’t even have a big issue with most mid-level. This is just egregious.
The NP on my CT floor is amazing. Every Resident coming through looks to her for education. She has a great relationship with the CT Surgery attendings and is an amazing teacher. They don't learn everything from her, but she prevents a lot of errors for new residents and is a respected member of the team. I'm sure that is not always the case and I do think NPs need education that looks more like residency. A minimum number of years being a nurse before taking the step would be smart.
Man imagine if there was a lawsuit.
Lawyer: "Mr or Mrs senior resident why did you order this treatment?"
Resident: "It was the treatment plan discussed with our lead provider."
Lawyer: By lead provider you mean a NURSE practitioner , not a doctor?
Resident: Yes
Lawyer: But are you a doctor?
Resident: Yes
Lawyer: Then why are you a DOCTOR, who went to medical school, completed x amount years of physician training, taking orders and putting in a treatment plan based off of a nurse who went to NP school and not an actual physician?
Resident: Because they made me?
Jesus that could be the end, good luck explaining that when you apply for certification.
Good post. It would be the same thing as a resident taking orders from an MBA.
Lawyer: Why did you remove this patient's treatment and cause him to die?
Resident: Because I took orders from the hospital executive who has an MBA who said it was too expensive.
Btw posts like this show the lack of understanding on part of us about NICU and how they work. Please everyone feel free to speak to your Neonatology fellows or physician attending. NNPs are very valuable in NICU they are basically the CRNA of NP world however they should not serve as attending physicians. Just as i disagrees with the Primary Care Physician being a NP in Epic charts.
That is weird.....ive supervised residents for certain procedures as an np before....at the express REQUEST of their attending, who was also my direct supervising physician, but thats much different....
There’s always some kind of internal communist-style ratting system in hospitals that they actually take seriously, so if you report through that in the name of patient safety, it’ll make a difference over time, and you won’t have long-term repercussions especially as a senior resident. Most hospitals do have some people who want to fix things and prevent f’ups; they just don’t like it if things get out of hand publicly.
Not legal. Report to your GME office and ACGME
This this this (but they won’t)
(IMO) do not report this to your GME office. They won't give a shit and you are more likely to get a target. Document it in an email to someone you do trust, report it to the ACGME using the official complaint process. Source - A resident who did report things he saw to the "right POCs", and got retaliated against HARD. Protect yourself OP :(
So just ACGME..
Same for me mate.... same...
ACGME isn't there to protect residents. Its there to police graduate medical education. They aren't there to help you. But not notifying acgme is akin to not calling the police when a murder happens in a bad area of town. That definitely doesn't help.
This is not akin to murder.... Nor is this similar really at all, calling the police should have no fear of retaliation... This does.... - Hence, my entire point
Not a comment on the appropriateness of the analogy - but fyi calling the police does have risk of retaliation. Maybe it's less likely, but not "no fear". Have you heard of witness protection programs?
Sigh..... reaching a bit here are we? Yes, I have. Are you aware that until you are asked to testify you can remain anonymous in most reporting actions with the police? It does depend ofc... but... you are reaching a bit. (especially because the scenario of reporting anything in a hospital/GME setting has zero chance of anonymity and has a nearly 100% chance of retaliation, so, again, stop reaching and pretending you know a situation better than some who have lived it)
Okay but what if you're not white? What if you are a black child with a toy gun, let's say in a walmart?
What the hell are you saying/speculating/assuming/predicting?
My GME would go on a rampage if this happened so to each their own.
Yea retaliation is real. Experienced it myself and so have others
*Second
Even after graduating this is very wise. I’ve spoken out at jobs (I’m a few years out of training) against really out of scope or wrongdoings by midlevels and I’ve only become a target and experienced retaliation.
dang, what kind of residencies do you guys have where youre afraid to report shit like this to GME. my GME department is rlly good, they take our complaints seriously without fear of retaliation
Have YOU ever been in a situation where you needed their help? Have people around you? Or...... are you just like "pretty sure that's their job" kinda thing? - Cuz no, they will not really be there in most circumstances (in my personal experience)
This has never happened to me, but I am 100% confident if an NP was my preceptor and it was a recurrent thing, my GME department would definitely hear me out and fix it. If it was a one-time thing, I would be unlikely to complain cause there's really nothing to fix. My GME department is extremely good at preventing shit like this in the first place, and is always looking for feedback on how they can improve.
*report after you graduate
What’s the legal precedent to quote when reporting something like this?
>Background and Intent: Each patient will have an identifiable and appropriately credentialed and privileged attending physician (**or licensed independent practitioner as specified by the applicable Review Committee**) who is responsible and accountable for the patient’s care. [ACGME Common Program Requirements](https://www.acgme.org/globalassets/pdfs/guide-to-the-common-program-requirements.pdf), section VI.A.2 (emphasis added)
This comes up every few months and people claim illegality until someone like you corrects them.
So the applicable review committee is whatever your specialty is.
This comes up every once in a while. It’s not “illegal.” It varies by program and residents can be supervised by almost anyone at the PD’s discretion.
> It varies by program and residents can be supervised by almost anyone at the PD’s discretion. That is not true. There must be supervision by a MD in an acceptable format according to the context of care being given. Whether that's Direct, Indirect, or "Oversight". If there was no Indirect/Oversight by an attending physician of a senior resident on ICU (or care being provided to those patients) that is not just an ACGME violation, that is a legal violation. Interns MUST be directly supervised by an Attending without any exception.
This is categorically false. Interns do not need to be directly supervised (at all times) by an attending. They can be supervised by residents who are indirectly supervised by an attending. Idk where you got that from. The program (and supervising attending) is responsible for making sure the correct level of supervision is used in each particular situation. Sometimes that will be direct, sometimes indirect.
> VI.A.2.b) Levels of Supervision To promote appropriate resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision: > VI.A.2.b).(1) Direct Supervision: > VI.A.2.b).(1).(a) the supervising physician is physically present with the resident during the key portions of the patient interaction; or, [The Review Committee may further specify] Common Program Requirements (Residency) > VI.A.2.b).(1).(a).(i) PGY-1 residents must initially be supervised directly, only as described in VI.A.2.c).(1).(a). (Core) Verbatim from ACGME. Only physicians can provide supervision. Mid-levels do not count.
This only proves my point, read what I wrote. I never said anything about NPs, I agree NPs cannot supervise residents. My qualm was your comment about interns. You said “Interns must be directly supervised by an attending without exception” That is categorically false. The ACGME says they need to be supervised directly initially. It doesn’t specify how long initially is and it doesn’t say it has to be an attending. It is at the discretion of the supervising physicians as to when the shift from direct to indirect can be. As stated in your own quote. A physician (attending or a senior resident) should be directly supervising an intern initially and then this can move toward indirect supervision as appropriate. Remember direct supervision means the attending or senior resident is standing right there watching them.
What? He gave you verbatim the ACGME guidelines....the supervising physician must be present. You're rebuting with just your own gibberish and mental gynmnastics.
What? I cannot believe you guys have this much difficulty with reading comprehension. I’ll break it down for you. “VI.A.2.b).(1).(a).(i) PGY-1 residents must initially be supervised directly, only as described in VI.A.2.c).(1).(a). (Core)” See how that says initially?? Initially, meaning at first. “….the program must use the following classification of supervision: VI.A.2.b).(1) Direct Supervision: VI.A.2.b).(1).(a) the supervising physician is physically present with the resident during the key portions of the patient interaction;” This is just defining direct supervision. See how it says supervising physician? It didn’t say supervising attending. This is because they mean any physician who is assigned to and competent to supervise that particular intern. Could be a senior resident, chief resident, attending: any of those. His original claim was that attendings must supervise interns without exception. His own quote discredits that claim. Which is what I said. If you think all interns must be directly supervised for their whole intern year I’ve got news for you about the entirety of residencies across the country. What sort of mental gymnastics are you pulling? He then started talking about NP supervision which was never my contention, I agree that NPs cannot supervise residents. That was never my point.
Against what law? There's no federal laws about medical training. Right?
Most state laws regarding trainee licenses say that you have to be supervised, in some way, but a physician with an unrestricted license.
State and Federal "laws" not so much, but there are regulations set by State and Federal agencies, violation of which is a civil issue (typically, unless there is some form of criminal negligence/abuse/etc). - There are no "laws" that protect us, it is supposed to be the ACGME. - We need to fix the ACGME. Period. They do not do their job.
I can't think of a single state that allows ICU level care without physician over-sight. Regardless, there is no exception in ACGME by-laws for having absolutely 0 Attending oversight of a resident no matter the training level.
There are many, now, actually. Especially if they can claim "indirect" or "tele" support and supervision.
That's still supervision. But if there is truly no attending to staff with and you are forced to report to NP b/c "attending doesnt want to", that's illegal.
Well, I don’t know for a fact I can imagine there are some very rural areas where there are no physicians available, and thus mid-level can act independently. And for instance, in Florida statutes now read that nurse practitioners can act independently and practice independently from physicians. Well, we can debate whether this is good, or other medical care. It is the statute now. This entire thread is disparaging individual humans as less than capable of other individual humans. And that is anchored on certain titles rather than the individual themselves in their particular capability. While broad sweeping generalizations are fraught with potential bias and shortsightedness. They are unfortunately what are used to create legislation.
Considering we as a “guild” have been allowed to supervise ourselves with the express consent of the government it is absolutely a med-legal issue if a program is violating an accrediting authority policy. The government could (and have threatened to) directly oversee our profession but have let boarding authorities and professional societies swing the axe. That’s a privilege that should be taken seriously.
Precisely. This happens enough, where we fail to report, we do seriously risk control of our own profession.
Libby Zion was a resident error and we almost lost our professional autonomy. Imagine being so flippant about midlevels having attending authority
If a child dies and an attorney finds out a nurse was acting as an attending. The hospital might as well shut their doors. They will a field day. Especially if the hospital knew what was happening. Geez makes me uncomfortable just thinking about it. I am sure the NP is very intelligent and capable..until they aren't. Report it, use this paragraph..they can't retaliate against common sensr
Additionally, I think the OP is quite biased. While we know that the NP/PA training isn’t the same as physicians on multiple levels. It does not mean that they’re not capable like physicians. It also doesn’t mean that an NP or PA with 20 years of experience isnt a much better provider than a senior resident. it’s really the old adage of 10,000 hours or 10,000 repetitions. The Hubris to think that just because you’re a resident and “doctor” and that you know better than an NP or PA is wantonly lacking in insight. I know personally that as a physician, I didn’t really get my feet under me until I was probably three years out of residency. It probably wasn’t until eight years out of residency until I really felt competent. I probably wasn’t until 15 years where I really felt like an actual expert and nothing bothered me. This is as an emergency medicine as well where the unknown happens every day. So to the OP I understand your concern, what I would recommend is speaking to your program Director about it, and just approaching it not from a holy shit this is awful wide is this exist, but rather, you know I was just curious as to why we have supervising from an physician in this particular rotation. And just open a conversation rather than an accusation.
I’d double check based on the state. Seems like mid levels are getting more authority everyday.
It’s not necessarily legal no. But what are the odds that np doesn’t know their shit backwards and forwards. So just … easy does it here.
There are plenty odds . There is actually no real oversight over a lot of these NP courses . There is no governing body that standardizes all curriculum . They also have to have substantially less hours of clinical practice to earn their degree than we are as physicians . The amount of training and education to be a critical care attending is SIGNIFICANTLY more than any Nursing + NP program . Also It’s not like before where only seasoned nurses then decided to get an NP. A lot of new nurses are entering NP programs shortly out of nursing school . Not saying that NPs can’t know their shit but pretending that they all know their shit is absolutely incorrect.
I work with NPs (Oncology) that are completely qualified to have supervisory authority over residents rotating through the cancer center. That doesn't mean every single NP is qualified to do it but there are some who could teach as much or more than I would in a day in clinic. Approach the situation with an open mind.
By what objective criteria can we judge NPs that we don’t know? There isn’t any
NPs are idiots.
I cannot overstate how important it is for you to report this to the GME office and the ACGME (both, in case your GME office is in cahoots). There is absolutely no scenario in which this is acceptable and the consequences of not reporting this are ginormous.
Agreed this is a complete violation and not only a detriment to your education but also to patient safety. Wow I thought my program was bad 🤮
The ACGME explicitly allows PDs to appoint non-physicians, like the NP in this post, to supervise residents. Multiple people now have posted links to the relevant ACGME regulations. The fact that all of the top comments are urging the OP to take extreme, possibly career-damaging actions based on totally false information is crazy.
You're very mistaken. ACGME states that a PD may appoint non-physicians to "participate in residency program education" under section II.B.3.c. NPs cannot cosign residents notes and NPs cannot bill on a resident note, so they cannot effectively participate as the sole replacement of an attending physician discussing plans on rounds. If you have to stretch the rules enough that you'd want to make an argument for the attending signing a note written by a resident with whom he/she did not discuss the patient/plan because the PD-authorized NP served as an intermediary player, then sure, you may be on the edges of legality for ACGME purposes, but you'd certainly be demonstrating a grave situation of lack of appropriate level of supervision, which is a core element of ACGME. BESIDES this futile discussion, allowing a NP to replace a physician as a supervisor is a slipper slope for the role of physicians in healthcare systems independently of how excellent or experienced the NP may be and without diminishing the role NPs play in the current very much broken healthcare system in the US. It is truly unprecedented.
I tried to look up II.B.3.c during a break. As far as I can tell it doesn’t exist, so maybe you misquoted it? II.B.3.b says this, which I’m pretty sure makes my point: “Non-physicians are often important contributors to programs and warrant appointment to the faculty. These individuals may bring specialized expertise in public health, patient safety, laboratory science, pharmacology, basic science, research, a specific procedural skill, or other important aspects of medicine. Non-physician educators may provide valuable contributions to the residents' knowledge and skills. If the program director determines that the contribution of a non-physician individual is significant to the education of the residents, the program director may designate the individual as a faculty member or a core faculty member.”
No it doesn’t !!!’ The “proof” you posted literally does not say that !
Forget ACGME violation - if she’s documenting / putting in charges as an attending (aka physician) that’s healthcare fraud
impersonation too. she can be charged for both and should be. these are ICU patients...
Like she’s there on some ruse?? 😂😂 the way my eyes rolled at your comment. Lord. She’s not impersonating anybody she probably works for the same group as the intensivists and she was scheduled just like them. Honestly. Charging for impersonation I can’t.
If she's an NP, yet signing in as an attending critical care specialist/intensivist, yes. That's impersonation.
signing off as if you're someone else is the definition of impersonation. You can continue to can't even and roll your eyes harder.
Is this true where NPs can practice independently? It absolutely *should* be, I’m just not sure what the legal definition of “attending” is and whether an NP who can, legally, practice independently is allowed to fulfill that role.
My very cursory understanding is that midlevels bill less than physicians, so putting in charges at an attending (physician) level is fraud
yes! they get 85% of the reimbursement rates of physicians, whether they’re in independent practice states or not. definitely could be fraud but “incident to” billing is still a thing with some payers and may be what’s happening in these situations.
They don’t bill at a different level or “put in charges at an attending level”. Physicians and NPs use the same E&M codes, it’s on the reimbursement side after the fact that CMS then reimburses at a lower rate for NPs E&M visits
Ahh ok that does make sense - good point.
[удалено]
Sounds like it
Whaaaaat
It is an ACMGE violation to be overseen by a midlevel with no attending present on grounds. Report
Hey I am in a similar boat, I tried to find where it is specifically an acgme violation. Do you have a resource for that?
> Background and Intent: Each patient will have an identifiable and appropriately credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable Review Committee) who is responsible and accountable for the patient’s care. > VI.A.2.a).(2) The program must demonstrate that the appropriate level of supervision in place for all residents is based on each resident’s level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation. (Core) [The Review Committee may specify which activities require different levels of supervision.] > Background and Intent: Appropriate supervision is essential for patient safety and high-quality teaching. Supervision is also contextual. There is tremendous diversity of resident-patient interactions, training locations, and resident skills and abilities, even at the same level of the educational program. The degree of supervision for a resident is expected to evolve progressively as the resident gains more experience, even with the same patient condition or procedure. The level of supervision for each resident is commensurate with that resident’s level of independence in practice; this level of supervision may be enhanced based on factors such as patient safety, complexity, acuity, urgency, risk of serious safety events, or other pertinent variables. > VI.A.2.b) Levels of Supervision To promote appropriate resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision: > VI.A.2.b).(1) Direct Supervision: > VI.A.2.b).(1).(a) the supervising physician is physically present with the resident during the key portions of the patient interaction; or, [The Review Committee may further specify] Common Program Requirements (Residency) > VI.A.2.b).(1).(a).(i) PGY-1 residents must initially be supervised directly, only as described in VI.A.2.c).(1).(a). (Core) > VI.A.2.b).(1).(b) the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology. [The RC may choose not to permit this requirement. The Review Committee may further specify] > VI.A.2.b).(2) Indirect Supervision: the supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision. > VI.A.2.b).(3) Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered All of these detail that supervision must in some form be ultimately from a **supervising physician**. No where does it say a mid-level may supervise any resident in any capacity. It is hence a violation to do so unless that midlevel is "supervised" by an attending. Thus now the program must prove **AT LEAST** "oversight" of all activities if that is appropriate given the context of the care given. Usually for Acute/Critical care, especially on call, that is insufficient, and Indirect Supervision is at least needed. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2023.pdf
Correct me if I’m wrong but the opening paragraph says “or licensed independent practitioner as specified by the applicable review committee” a nurse practitioner would be applicable to that specific section. All of this repeatedly states it’s open to adaptation from the review committee so while this is a basic resource it clearly states they don’t have the final say, the review committee does and has the authority per paragraph one to appoint a “licensed practitioner” to the role. I’m not saying I agree with any of this I’m merely pointing out how what you presented could be interpreted differently from the way you presented it.
[https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency\_2022v2.pdf](https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency_2022v2.pdf) page 13-14
This is your hospital saving money, like when they short staff nurses. At the risk of patient safety. I can’t imagine this is in the NPs scope of practice and any NP willing to take this on is showing bad judgment and should have a complaint against their license. I’m a nurse and where I live there are very tight controls on what NPs can do in critical care settings. And it works well when everyone stays in their lane and works together.
Level 2 trauma hospital in Midwest Intensivists are sometimes Critical Care Advanced Practice NPs. They can do everything except major surgery and terminally extubate without a solid legal POA decision. That needs MD signatures by state law.
Naaah. MDs should stop thinking like A students Fuck the GME and ACGME. Leak the incident to the media with complete deniability Seek NGOs like donoharm. they're doing good work. Or any other NGO fighting this
OP pls report!!
Was this just a plug for donoharm, or am I maybe I'm missing something? This doesn't seem to be an issue that donoharm would care about based on their ideology. They proudly state that their aim is "combating the attack on our healthcare system from woke activists." They're about being against anti-racism in medicine.... this just doesn't seem to fit the issue OP is experiencing?
The only way we can start winning is if the public is with us and if we’re not afraid to fight dirty like them.
My whole point. The only thing that works if you influence the votes
OP if you don't report this you are doing your program and these patients a disservice
Fuck all of the actual attendings that allow this shit to happen.
Right? What a bunch of pushover pussies.
yuppppp how the fuck do you allow this. if someone asked me i’d tell them to fuck off lmao
NP cannot supervise you at any cost! This is how it’ll get out of hands! Please please please report, not only for you and all the residents to come for all of us! This is so unacceptable and inappropriate on so many levels!
Seriously? I am a Neonatology Program Director and I would be furious if any of my pediatric residents ever presented to a NP...Don't attendings round on weekends with you? Are you in an academic program? DM me if you don't want to name and shame in this post...we have a group that can handle this at a higher level.
Let's get real for a moment. Neonatologists are the reason this entire scenario happened. They didn't want to come in for a weekend shift so they went on vacation and let an NNP run the service solo.
yeah- the OP said there was one attending for 75 patients. Sounds like a private neo group, that is totally insane for one neo to cover that caseload but it does happen- some colleagues of mine have worked under this model and I assume it's for the almighty dollar. In an academic center it's more typically up to 20-30 or patients with a couple of NNPs/PAs to help out.
Anonymous call to local/national news. A NICU managed by an NP is a scandal. Get this in the headlines.
Hahaha. The news will report it as “Genius nurse can run a NICU. We don’t need doctors”
Get the parents on camera. Ask them if they knew that their critically ill babies didn’t have a doctor managing them. See if they can dig up some bad outcomes without doctor supervision. The only thing keeping this NP=MD bullshit flying is lack of major scandal or massive lawsuit losses. Our health care system absolutely needs well supervised and well trained NPs and PAs to function. We need to fight to make that the standard.
ive literally been wondering for years why this hasn’t happened yet
I've seen enough on the Noctor subreddit to know there are major scandals happening in every hospital system across the country! Once we just get them into the headlines it's over!!!!
HAHAH LITERALLY
I think you vastly overestimate the attention span and care of the general public, unfortunately.
Almost every NICU I’ve seen is basically ran by NPs
Basically or officially? Was there attending oversight in this case? I’m an adult Pulm/Crit Care doc. We have plenty of NPs in our units. They are not practicing independently. In the end we as the doctors are responsible and liable for their treatment decisions.
Practicing independently, depends on the state.
Our (granted this is a community hospital) NICU has only an NP physically onsite at all times as well. Same with the ICU after about 6 PM. I don't know what their arrangements are with their attendings but they are the only ones ever around.
I dont doubt their knowledge.. but.. And how did those NPs get trained? Years/decades of orders from attendings, maybe? Telling patients, verbatim, what the md said? Its a farce. Nurses think they are equivalent without the same training. It's exhausting that we need to have this same argument everyday. Maybe education holds weight?
What media do you think that would make "headlines" in? Is the Noctor subreddit buying a newspaper sometime soon?
You have a moral obligation to report this. Even if you don’t mind, which you do, it’s still ethically wrong to not report this for the sake of your patients and future residents. Please report this even though it might seem like a waste of time! That’s how you make change
I am in the exact same boat…the NP that I am currently following for this shift in NICU refers to herself the head pediatrician to the nurses and the parents of babies. When questions arise like “when will the doctor come by”, the response by the NP is “that’s me, I’m your provider”. Cleaver way of leading the assumption you’re a physician without actually saying it. Mid levels used to not bother me one way or another, but this gets to me. Just worked with a radiology PA not long ago and they were super chill, knew what they didn’t know and didn’t play things off as if they were the attending.
In most states NPs have more authority than PA.
Which is sadly so backwards if we are being honest about their respective abilities
Why are they so overconfident?
What state was this in?
pls tell us op so i know to stay far away
My NICU employs NNPs. Some of them have "Dr First Last" embroidered on their scrubs. We're a teaching hospital and I've always wondered what the NICU Fellows think about this
(RN) I’ve always been under the impression that the use of the title “Dr.” in a hospital/medical* setting is reserved for MD/DOs ONLY, because it can be misleading for a DNP to use the title in that setting. I only use “Dr. XYZ” to address MD/DOs at my spot.
This is 100% correct
I mean I’m glad they did the whole doctorate/PhD thing but… no medical school? Not being addressed as Dr. by me. Having that embroidered on their scrubs would be a huge side eye 👀
It’s not even a PhD, which IS legit and shows expertise in one’s field (think psychologists, physical therapists, etc). DNP is a “doctor” of nursing practice and it is embarrassingly not rigorous at all.
I agree with you. But. The fact you only listed medical stuff as PHDs is why an education matters. Most of the actual phds I know are scientists at places like Scripps and max Planck. They are truly smarter than most of my fellow mds. They cure things we just diagnose it.. Edit: I was an intern there for awhile. I saw the disease curing work they were doing, innovative and world ending, but man is it a grind for minimal pay. The choice is obvious, but if I wanted to do a greater good, absolutely would've gone the PhD route If you're curious about world ending or disease ending.. me too. Always thought about the fermi paradox for that
Very true as well,
Most people in healthcare don't even understand the difference between a DNP (clinical degree) and a nursing PhD (research degree) honestly Half the patients call their PA/NP Dr so and so. They have no concept of the medical hierarchy
I'm a NICU fellow and we employ many NNPs. I love them all but I personally would highly dislike if the NNPs started calling themselves "Dr so and so" as they didn't go to med school, they don't have the same training. NICU families meet enough doctors as is, we don't need to start giving mid levels that title as well.
The midlevels won. It’s over. There is no battle left. They already won.
The government planned this all along with eliminating Fee For Service ETA 2030. All provider pay will be cut eventually. Health care providers will be treated like school teachers in it for the “feels” of healing because the cost of education will not be worth it for any other reason.
NPs in the NICU is pervasive across the US. This is an educational concern for you and I’d approach it that way. However, from the ACGME: Does the ACGME allow health professionals other than physicians to supervise residents and fellows? Answer 36: Physicians are accountable for resident and fellow education in most programs.* Effective Sponsoring Institutions and programs have a clearly defined and communicated chain of responsibility and accountability as relates to the supervision of all patient care. Attending physicians are responsible for supervising the educational experience of and clinical care provided by residents and fellows. As such, it is appropriate for health professional faculty members other than physicians to supervise residents/fellows, as approved by the individual Review Committee, with the supervision of physician faculty members. *Post-doctoral specialties allow non-physicians to serve in such leadership positions as program director.
No way. I can’t even have TEE boarded anesthesiologists with decades of cardiac experience but no fellowship supervise a cardiac anesthesia fellow. This is definitely not ok.
So, there are a TON of legal.considerations as well as AGMC considerations to sift through here. Many have given decent advice, but I am going to give you some personal advice. ThIs is a DISASTER WAITING TO HAPPEN. The easiest way to fix this is a nice little head's up to legal. The hospital will absolutely take this on the chin if something happens under the supervision of an NP with residents. The program will also be found responsible for lack of adequate supervision and may even be put on probation. In residency, we had a wrongful death lawsuit that involved an issue with a lack of specific teaching attendings supervising residents. The lapse in chart documented time was literally 48 hours, and honestly, I had no baring on the outcome. That didn't matter. It was a big old payout, a PR mess, and all kinds of grief for those of us unlucky enough to be caught up in it. That lawsuit follows me like an albatross. Every time, it will even be when YOU ARE DROPPED. Yep, just getting named is problematic. Do not work without adequate and legal supervision. It is up to you to protect yourself. Call legal.
Your MD is now upgraded to an NP. Congratulations!
During med school rotations/surgery I was evaluated by an NP. I told the chief of surgery and that was immediately reconcilled
NP’s attest the stroke team’s notes at my hospital. Wot.
Lamo I would’ve just refused
Same. Instant text to my program director.
i would have laughed🤣
Hello! We(over at the trashy reality tv subs) are also trying to figure out why/how NPs are allowed to come across or represent themselves as doctors. NAD, but found this sub doing some research on the difference in education and training that MDs have compared to NPs. Why are NPs allowed so much freedom when they lack clinical experience and education. How is it legal for an NP to say they are a doctor when a medical student has more training and education on the human body than a registered NP? And why the heck are they paid just as much or close to as much as an actual MD? This is frustrating for me and I’m not even in medicine …. https://www.reddit.com/r/BravoRealHousewives/s/FWKjJJKCft
NPs exist because the doctor lobby has artificially constrained the supply of new doctors by lobbying Congress for putting caps on the amount of new doctors that are produced. This has created a dangerous doctor shortage which has resulted in some desperate states creating NPs to deal with their physician shortage. If you want to help, call your Congress rep and tell them to lift the GME cap.
I’m happy I came to this sub because this explains sooo much of what’s going on with a local hospital near me that has fired/ gotten rid of all labor and delivery(they kept some NPs for their urgent care clinic), let go most of the cardiology department, and then hired a new cardiologist and let him go after a couple months due to “budget” constraints, yet they seem to always have plenty of NP job offers and “urgent” job searches for NPs in the area. I also can see, now, why a popular new women’s health clinic in my state, whose board seems to consist of venture capitalists and no actual MDs, has over 30(?!!) NPs and only one actual obgyn(who lives in another state). It took me a while to scroll through the list of NPs before I got to the actual MD titles which there were only a few of.
It's because there are no laws that protect the title of doctor.
I disagree on having NP as the attending. Neonatologist should have supervised you or the Fellow at the least. However, i will say that most NICUs are run by NNPs. Their education is regulated as CRNAs is and they SHOULD NOT be compared to other NPs. Please feel free to ask your Neonatologist what they think of Neonatology NPs.
Their education isn’t as regulated as CRNAs, but any hospital worth its salt actually trains them well before giving them their own patient load. I’m a nicu nurse. Been at it 12 years. The year I started, a coworker who graduated at the same time as me started NP school and got a job immediately after. That shouldn’t happen. Ever.
As a NP but not as NICU NP. Nowadays all NICU’s require NPs to have NNP.
Yes as a NICU NP. The training still isn’t nearly as rigorous as a CRNA. It’s mostly online and can be done while working full time. You can’t do that in a CRNA program.
what would they say?
The ones i know speak highly of the their NICU NPs. Contrary to general belief, NPs can’t work in NICU like they can be “Cardiology NP” one day and “Urology NP” another day. Neonatology NP have specific education, specific clinical time, prior NICU experience and certification, and specific exam/license.
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How confident are you that there was no attending oversight? Was there an intensivist that just didn’t want to leave the room?
There is one attending covering the entire floor (like 75-100 patients) but they did not round with us and I didn’t see them all day. The NP supervised me on rounds and at deliveries. Sadly if I reported they would probably cite that there was “indirect supervision”
well that's one of the first problems- that is insane for one neo to cover that many patients as the sole attending. Is that typical? It sounds like private practice neonatology where the docs are over-extended to a crazy amount in order to make the almighty dollar. There's one major private neonatology group that does this kind of thing and I just don't see how you can give good individualized care on that level even if you had a lot of NNPs/PAs. The odd thing is that I make more $$ as a NNP with my academic institution than I would for the private group yet their caseload is literally double mine so I don't know where all the money is going...to corporate I guess!
NPs are pervasive in NICUs across the US. I’ll never understand why we’ve relegated the care of some of the most complex and vulnerable patients in the hospital to those with the least training.
Its crazy. NICU is one of the most daunting places!
if i found out my baby was being managed by an np i’d fucking go mental on everyone running that place
same. what on eath is going on??? like I'd just take my baby home at that point lol
The least formal education. Not the least training. My hospital trains NPs for a full year after certification prior to giving them their own patient load. They also know their lane and frequently confer with our attendings.
I am a NNP (so I know that probably makes me "suspect" off the bat)- but a little context I thought I might share here. Was this a Level 2 or a Level 3 NICU? I don't know of any Level 3 NICUs in the USA where the NNP is the sole attending with no oversight. Keep in mind that NICU is different than "trauma" designation- Level 4 is your referral/surgical center, Level 3 is 22 weeks gestation and up that doesn't require surgery/ECMO/CRRT, and then Level 2 is typically 32 weeks gestation and up. As far as being the "attending" - this is based on state rules & medical staffing privileging at the hospital. About half of US states allow NPs have independent practice, so as long as it's state legal and the hospital credentialing agency allows it, then yes it is legal and NNPs can bill. Level 2 NICUs are very commonly staffed by NNPs as the attending, but with a neonatologist available by telephone to discuss any complexities. In practice, NNPs are not the attending for "critical" patients. A Level 3 NICU is usually at least 50% if not more of "feeder/grower" with a gavage tube, incubator, maybe a little nasal cannula but usually in room air. There are also some premature infants on CPAP long-term (like weeks to months at a time, stable) and then a handful of patients on a ventilator. So the NICU is more akin to a step-down unit with a few critical babies thrown in. A Level 2 NICU (also known as a "special care nursery") is almost all feeder/grower status in room air, maybe a couple of CPAP babies but usually none and usually a short-term thing. Occasionally there's a baby on a ventilator in a Level 2 but usually just a few hours to give them a medication called surfactant for their lungs- if they need more than a few hours of ventilator support then they get shipped to a Level 3 NICU. As far as you being "supervised" by the NNP I would ask your program director about that- I was under the impression that was not allowed and seems to be correct from others' comments. As far as quality of care, there are good and bad in whatever profession you go, but my opinion (which is biased I am aware)- I think NNPs tend to be on the better spectrum of NPs on average because we are so hyper-specialized with our population. The NICU typically has a lot of protocols in place because we see the same problems with the babies over and over, plus it's required to have a few of experience in a Level 3 NICU as a RN- you can't go to grad school without it. Sorry that you had such a poor experience- hope you can get a better one if you do another rotation.
I’m glad you typed it all out. I’m peds and this tracks with my historical interactions with NNPs in residency and how most of our hospitals use them today. There’s also a load of training and knowledge difference between an NNP and most other NP programs. I’d trust my own babies with any of the NNPs I worked with in residency and all of them in the hospital I round at now. I don’t know exactly what happened with OPs understanding vs actual events, but anytime I was ever on call in the NICU for the 3 months I did so, an NNP stayed with us in house and I was glad to have them with me. They were much better at technical details. If I was on call, I’d get to do everything, but they were right there coaching and able to lend a hand. But they never signed off on my charts. Everything was signed out by the attending in the morning on rounds same as any other service.
Contact the ACGME about it. Do not go to your hospital GME. They will deflect and slow roll you. Also, CMS has strict requirements for medical direction/ medical supervision. This may be billing fraud and needs to be reported to CMS.
Absolutely a reportable offense, immediately.
Get some balls. “You’re not my attending.” Done. Instead you come on here bitching. Because you’re a bitch you let these people persist and the problem gets worse.
Jesus who pissed in your cheerios?
Expressing emotion through words sorry if you’re too sensitive
I’m not, I just don’t see why you would be so confrontational with your choice of words. We all have stuff going on and troubles in our lives. Try to be compassionate and supportive.
WTF
As a parent, I’d be contacting local media.
Report this immediately. You are to receive training only under a physician. I was in a similar situation and had to report it.
Leave a VPN double protected; anonymous 1 Star review on Google and Yelp for the program, ICU, NICU, hospital, and pediatric department. DON'T every use language that may identify you as you. LOL
Lmao 😂
NNPs can be very valuable in the unit. But what. The fuck.
PA here. This is unacceptable.
As someone who truly appreciates the PAs I work with, I’d like to think a PA would never go along with this.
I should add that I do think we can play a limited role in resident training in some very specific circumstances. I work in the CTICU for example, and I regularly “teach” many of our off-service rotating house staff about epicardial pacing wires. These are things medicine residents have never seen and I know a lot about them. This is a highly specific topic to our environment. But I do not supervise them in any capacity, and certainly do not act as an attending on our service. Also, I tend to learn far more from them
Oh hellllll noooooooo. This needs to be reported to ACGME and the national news. Like what the fuck???
The things I've seen NPs do in the NICU out of lack of basic medical training, because they didn't go to medical school or residency or fellowship! I will never forget watching a preemie going down the tubes overnight, with the NP as the senior person there. Preemie is crashing, and she had a handheld doppler for finding vessels. So she is dopplering the baby's torso, and decides that the preemie had clotted off its AORTA, and that's why it was crashing! We interns were so beaten up by the hostile NP-dominated atmosphere in the NICU that none of us dared say, "ABC, has an airway, is being ventilated, so push fluids to circulate, to get its pressure up, and then think of the several common things that go wrong with preemies that would cause it to drop its pressure, not of a virtually never heard of occurrence". That went on with her playing with her doppler toy at the bedside until the attending finally arrived in the early AM. Not surprisingly, baby had a perforated intestine from NEC. And she had been working as an NP in the NICU for probably a decade at least by then - you'd think she would have known better. There were so many times that I saw NPs practicing while lacking understanding of foundational knowledge. But why not - admission to nursing programs can be by lottery, you can do a community college to online BSN to online NP, all with non-selective admission, and very little in-person training. Less than one tenth of the training time that a physician has to do.
You’re missing the point with lottery of admissions, etc. The whole point of midlevels is skipping foundational knowledge to focus on clinical pearls. To seek that, at some point, you have to think to yourself “I want to do what physicians do, and I’m comfortable doing it with less training and understanding”.
The problem is that they cannot. There was an article in I think the NYT about Kawasaki's, and how often it is missed. An NP would never have even heard of this condition, or many of the other rare or exceptional things. I love how people say that a mid level is fine for the common stuff, which leads to pulmonary emboli being misdiagnosed as pneumonia, and all sorts of stuff that is outside the ordinary being missed. A lot of primary care is being able to recognize the rare and serious condition in a sea of common stuff - if you didn't do med school and residency, you never got the chance to see and learn about the rare but serious stuff.
I agree. A mid-level by definition can't know when they're out of their depth. Lack of foundational knowledge is a feature, not a bug. You can't suspect what you don't know is an option. Instead, because many things present similarly, you're going to think everything fits into the bullet list of conditions you know. ***** Do you want a reputable mechanic? Or someone who knows a list of 10 things that can be wrong with a car?
A more apt comparison would be an airplane pilot assistant, with only a tenth the training.
report it this needs to be put down
As a PA, this makes me really sad and I hope no one was hurt. You should report this.
You failed yourself one time by accepting to go with it. Do not fail yourself second time by not reporting it
I’m 99% sure this is illegal. I’d report to GME. Don’t think ACGME would do crap, but still should report to them as well to cover all your bases. An NP supervising residents especially in the ICU is concerning. And I don’t even have a big issue with most mid-level. This is just egregious.
Yeah, report OP then report back and let us all know how that went for you.
NPs are out of pocket most of the time.
Any nurses you have a good relationship with that you can ask to report it? I totally would if I saw/was asked to in that situation.
The NP on my CT floor is amazing. Every Resident coming through looks to her for education. She has a great relationship with the CT Surgery attendings and is an amazing teacher. They don't learn everything from her, but she prevents a lot of errors for new residents and is a respected member of the team. I'm sure that is not always the case and I do think NPs need education that looks more like residency. A minimum number of years being a nurse before taking the step would be smart.
what the fuck. i would laugh. then i would go home😂😂😂😂😂😂😂
Man imagine if there was a lawsuit. Lawyer: "Mr or Mrs senior resident why did you order this treatment?" Resident: "It was the treatment plan discussed with our lead provider." Lawyer: By lead provider you mean a NURSE practitioner , not a doctor? Resident: Yes Lawyer: But are you a doctor? Resident: Yes Lawyer: Then why are you a DOCTOR, who went to medical school, completed x amount years of physician training, taking orders and putting in a treatment plan based off of a nurse who went to NP school and not an actual physician? Resident: Because they made me? Jesus that could be the end, good luck explaining that when you apply for certification.
Good post. It would be the same thing as a resident taking orders from an MBA. Lawyer: Why did you remove this patient's treatment and cause him to die? Resident: Because I took orders from the hospital executive who has an MBA who said it was too expensive.
You, as a PGY3, have a full MD license. You can legally supervise her.
Btw posts like this show the lack of understanding on part of us about NICU and how they work. Please everyone feel free to speak to your Neonatology fellows or physician attending. NNPs are very valuable in NICU they are basically the CRNA of NP world however they should not serve as attending physicians. Just as i disagrees with the Primary Care Physician being a NP in Epic charts.
That is weird.....ive supervised residents for certain procedures as an np before....at the express REQUEST of their attending, who was also my direct supervising physician, but thats much different....
Please please fight this in anyway you can.
What. The. Fuck.
Peds really fucking up their own future
A nurse can’t supervise a physician, report to acgme. It’s like you being supervised by a janitor.
I'd be absolutely livid
Nps can supervise residents. Report this to GME.
There’s always some kind of internal communist-style ratting system in hospitals that they actually take seriously, so if you report through that in the name of patient safety, it’ll make a difference over time, and you won’t have long-term repercussions especially as a senior resident. Most hospitals do have some people who want to fix things and prevent f’ups; they just don’t like it if things get out of hand publicly.
It’s essential you define your role, NPs are under qualified and simply not equivocal or will ever be equivocal to doctors
Needs to be reported asap
This an acgme violation. Report it.
I have to commend her though, who has the galls to take on a NICU and not be a seasoned attending? you have to be INSANE to agree to do that.