ER mid-levels - how to get along with MDs.....

Joan Z · Nov 14, 2008

No wonder the "midlevels" didn't work out...

What is the advantage to having someone else doing the procedures if they need to be there anyway?

How much autonomy do NPs have in your state? Is the hospital not aware of what you could legally do on your own? Maybe if you explained (and showed them) what you could do legally and what you have been doing they'd let you go more independent.

I was in the ER as a student with another NP and she was pretty much on her own, they figured she'd ask if she needed help or just a consult. And she did.

Advanced Practice Columnist / Guide · Nov 14, 2008

Okay - so here is the score: Took a part time (10 hours/week) job in small (37,000 visits/year) ER that had a hx of mid-levels that didn't work out. I'm the first mid-level they have had in about 4 years. So...I was hired by the CEO and medical director of the physician practice that staff this ER (and some others). My role was never fully explained, except that I was to assist the physicians in expediting care. So....I have been there for only two weeks and its very very obvious that the physicians don't feel that mid-levels belong in the ER. In their defense, the hospital has not allowed me any privileges: I must have a physician physically in the room for ANY procedure: including pelvic exams and simple lac stapling!!! And...this is effective for the first two years!
So....my question is: has anyone encountered this and what did you do to develop a role where you didn't primarily see the pts but rather "assisted" the MDs?
Thanks much for any input....(so glad I didn't quit my day job!)

It sound like the physicians there are not familiar with the mid-level role in an ED setting. Unfortunately, they've already pigeon-hole you to not be independent based on the privildges (or lack of priviledges) granted to you for the next two years. Would it help to educate the medical director about the scope of practice for advanced practice nurses in your state? I can understand having to supervise you and be present for everything for a period of time until the physicians feel confident enough to let you do things on your own but two years seem to be awfully long for such a learning process. The other thing I'm thinking is usually priviledges are granted for one year when it comes to a newly hired mid-level provider. The successive priviledges are granted for two or three years after that. Would it help to bring up a review of your priviledges after a year of employment?

emtneel · Nov 14, 2008

well, have you asked any of them what they want help with? Or are the CEO and director not directly working in the ER and just hired you and then the odd relationship of the ER docs physically working there and you, don't know what the relationship is, and don't know what to do with you?

My last job, i worked for anesthesia and didn't really have privledges either....

Basically the NPs were there to do pre-op exam for the docs, research all the history and records and IF needed consult with the Anesthesiologist to see the patient.

This facilitated things by the Anesthesiologist could supervise a few CRNA's and see a few patients in the meantime and therefore a LOT more pts having surgery each day. I think this place did like 4x as many surgeries as all the other children's hospitals..

Anyways, was kinda dumb b/c we couldn't order any blood tests, x-ray, echos, etc without a physician. One of the head physicians thought we should be able to, since like duh, we are trained to do that.

i didn't really know til i tried to order an echo on a kid who'd had open heart surgery as a young child in Mexico and never had follow-up care or seen a Cardiologist since living in the US, HELLO, you need an echo before doing surgery.

But they called back asking which doctor order it, i was like I did, the NP, they said oh no, we have to have a doc... so anyways....

Maybe they just want you there to do H and Ps? Then present the pts to them?

I would hate to have someone standing there for every simple procedure...

Trauma Columnist · Nov 14, 2008

Joan - I live in IL and have been an APN for 2 1/2 years. It is truly just this hospital. Its like stepping into the dark ages.

PinoyNP - I actually had to have a meeting with the entire medical review board of the hospital where they asked me why I didn't become a doctor if I wanted to care for people! (I truly wanted to tell them there was little call for 50 y/o med students) but held my tongue. The medical director of the hospital is the one who is so strict. He made it very clear that if the rules are broken, I will be hx.

emtneel - this whole thing is kinda weird. I know the CEO and medical director because I worked with them in another ER several years ago and we had a great working relationship. They actually called me, not the other way around. However, in this ER MD practice, there are about 10 physicians and there are 3-4 that I have never met before this past two weeks.

In the end...I called the medical director today and asked for some role delineation. I know its frustrating for the MDs to have to basically do everything over that I do. So...my new idea is to the reassessments and not primarily care for pts. We'll see. My next shift isn't until Tuesday and hopefully by then I will have an answer.

Thanks much.

allnurses Guide · Nov 14, 2008

I don't mean to be flippant, but why did you take the job? Or did you only find this out after starting?

core0 · Nov 15, 2008

Joan - I live in IL and have been an APN for 2 1/2 years. It is truly just this hospital. Its like stepping into the dark ages.
PinoyNP - I actually had to have a meeting with the entire medical review board of the hospital where they asked me why I didn't become a doctor if I wanted to care for people! (I truly wanted to tell them there was little call for 50 y/o med students) but held my tongue. The medical director of the hospital is the one who is so strict. He made it very clear that if the rules are broken, I will be hx.
emtneel - this whole thing is kinda weird. I know the CEO and medical director because I worked with them in another ER several years ago and we had a great working relationship. They actually called me, not the other way around. However, in this ER MD practice, there are about 10 physicians and there are 3-4 that I have never met before this past two weeks.
In the end...I called the medical director today and asked for some role delineation. I know its frustrating for the MDs to have to basically do everything over that I do. So...my new idea is to the reassessments and not primarily care for pts. We'll see. My next shift isn't until Tuesday and hopefully by then I will have an answer.
Thanks much.

I've seen this before. At a previous job the cardiology NPs (and physicians) were convinced that the NPs couldn't do the assessment and the plan. They were confused when I would see the patient and schedule the patient for a procedure without the physician seeing the patient. Essentially the NPs there were data gatherers. At least they could order tests and do stress tests.

This is really about power. The medical chief is firmly stuck in the 19th century. He probably doesn't understand why the nurses don't stand at attention any more when he comes to the floor. It really depends on how much power the ER group has and how much political capital they are willing to expend on this issue. If the medical chief tried this at the small ER that I work at they would simply tell them to find another group. Their model wouldn't work without PAs doing most of the night time work.

The ED medical director should be able to credential any qualified provider for procedures. How much they are willing to fight is the question. If there is a lot of competition for the contract and they need it then probably not. If they allow you to order tests then you could do just diagnostic work. Otherwise I would talk to them and see if they can move you to another more enlightened hospital. When the medical chief asks why the wait times are long they can tell him.

David Carpenter, PA-C

Joan Z · Nov 15, 2008

Hmm, I have lived in IL and saw several NPs there (where I first learned about them) and they were fairly autonomous so must be some mini-Twilight Zone you stepped into...

So, you worked with the medical director before and had a good relationship, he seemed to get the concept of the NP, but now he is setting limits on your scope of practice? Why the change? Is it the physicians in the ED?

I won't generalize that it is only the older MDs who have an issue with the concept of the NP (frequently the ones who step into the hall and yell NURSE! and expect everyone to come running) because I have seen plenty of younger ones--who may be new and insecure in their roles--do the same. People's preconceived notions are based on what they have seen or what they have been told and are very difficult to change. Even if you demonstrate competence and show them the legal authority they may still think of you as NURSE! (and what is worse, the nursing staff may not support you either). You still have your day job, did you do this for extra $? Is it worth it?

Trauma Columnist · Nov 16, 2008

ghilbert - I took this job just as a PT thing to get back to the ER. I personally know the ER medical director and the CEO of the ER physician practice. When they asked to hire me, they did it with the idea that by me seeing some patients, it would take the load off the docs and then they could see the really sick people. Unfortunately that has not turned out that way. The hospital medical director is the one against mid-levels.

David - totally agree.

Joan - yes, in my day job I am very autonomous; I order tests, interpret them, refer to other physicians, talk to other physicians, etc.

Am not sure this job is going to work out and so very glad I didn't quit my day job. The hospital medical director made it excruciatingly clear that I was NOT to call or even talk with pts physicians' which leaves me seeing the pt, working the pt up, and then passing the pt off to another ER physician who hasn't even seen the pt in order to talk with the pts' attending. Needless to say, that's not going over well at all.

The other option is for me to see Urgent Care patients, but the problem with that is that Urgent Care is open 9am to 9pm and I work 6 pm to 11pm. However, again, since I can't see pts on my own, this is a bit redundant too.

I did express my concern to the ER medical director on Friday, so will see what kind of proposed solution he has. It took 4 months to get credentialled at this hospital so I know they don't want to let me go with only a two week trial.

ANPFNPGNP · Nov 17, 2008

ghilbert - I took this job just as a PT thing to get back to the ER. I personally know the ER medical director and the CEO of the ER physician practice. When they asked to hire me, they did it with the idea that by me seeing some patients, it would take the load off the docs and then they could see the really sick people. Unfortunately that has not turned out that way. The hospital medical director is the one against mid-levels.
David - totally agree.
Joan - yes, in my day job I am very autonomous; I order tests, interpret them, refer to other physicians, talk to other physicians, etc.
Am not sure this job is going to work out and so very glad I didn't quit my day job. The hospital medical director made it excruciatingly clear that I was NOT to call or even talk with pts physicians' which leaves me seeing the pt, working the pt up, and then passing the pt off to another ER physician who hasn't even seen the pt in order to talk with the pts' attending. Needless to say, that's not going over well at all.
The other option is for me to see Urgent Care patients, but the problem with that is that Urgent Care is open 9am to 9pm and I work 6 pm to 11pm. However, again, since I can't see pts on my own, this is a bit redundant too.
I did express my concern to the ER medical director on Friday, so will see what kind of proposed solution he has. It took 4 months to get credentialled at this hospital so I know they don't want to let me go with only a two week trial.

This is just amazing...what exactly do they want you to do?? I just posted a new thread asking advice on what to do about an ER doctor yelling at me the other day. I've been a NP for almost 4 years and I have NEVER had a doctor question me about a diagnosis or treatment. I just started a brand new job for a company that staffs ER's throughout the nation. I work at 4 different hospitals and I'm working the night shift. I had a doctor YELL at me the other day for ordering an x-ray on a patient with new onset thoracic pain. The doctor did this because he gets paid per patient (including the ones midlevels see) and it was towards the end of the shift. He wanted to get people in and out as quickly as possible, so he could make more $$$. My shift overlaps 1 hour with his and the first time I was at that hospital, he actually signed off on several charts before he left and I hadn't even seen the patient! He said, "See how much I trust you!" He didn't know me from Adam...it's toally about money.

That being said, I can't imagine being in your position. I would/could never work in that environment...no way, no how. I think a lot of these doctors are very worried about NP's taking over health care. It's not just the older ones either. A family practice resident told me that his peers in medical school couldn't believe he was going into family practice, since this was going to be taken over by NP's in the near future. I've heard several seasoned doctors make the same comment, especially now that Obama has been elected. I guess I don't understand all of the politics related to this, but whatever. If I were in your position, I would quit so fast! Be glad you didn't give up your day job!

Trauma Columnist · Nov 18, 2008

Yes, I'm very glad I didn't give up my day job. I work tonight and always take a deep breath before I go in - lol. I want to make this work, so will tread lightly.

Just curious - do you work for ECI? I've gotten some mail from them lately - they staff an ER where my husband lives and my ultimate goal is to work 2-3 days/week here and then spend half the week with my husband.

ANPFNPGNP · Nov 18, 2008

Yes, I'm very glad I didn't give up my day job. I work tonight and always take a deep breath before I go in - lol. I want to make this work, so will tread lightly.
Just curious - do you work for ECI? I've gotten some mail from them lately - they staff an ER where my husband lives and my ultimate goal is to work 2-3 days/week here and then spend half the week with my husband.

I work for EmCare, but ECI used to have the contract at these hospitals until 2 years ago. I think the EmCare contract is up in 10/09, so we'll see what happens. I was told that ECI paid $15/hr less than EmCare, but had excellent benefits. EmCare pays $60/hr...I thought they had good benefits, but apparently not. Their 401K doesn't have a match, they will "help" you find medical/dental/life insurance, but they don't pay any portion of it, etc. Oh well, unfortunately they pay more than any other job in this town.