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!)
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.
Good luck tonight - I'm right there with you! I'm filling in for someone tonight from 5-9. I'll get to work 1 hr with that doctor who yelled at me - please say a prayer for me! I found out that another NP is no longer allowed to work at that facility specifically because she got into it with that doctor. Apparently, he treated her the same way and she wouldn't stand for it. Unfortunately, they chose him over her, so she's no longer allowed to work there.
Since 2006 this ER staffing company has required all their docs to be board certified in ER medicine in order to work in urban areas (those who already worked for them were grandfathered in). That doctor is an ER doctor, so it's not like they're going to get rid of him or even discipline him in any way. Apparently, it's pretty tough to find docs who are certified by the ABMS in ER medicine.
Last night was pretty easy. The doctor was polite but made it clear I was to have only one patient at a time. So in 5 hours, I took care of two patients! Works for me - I get paid whether I see pts or sit around twiddling my thumbs. I try to keep busy at least looking at xrays, going into rooms to update pts, etc..
Last night was pretty easy. The doctor was polite but made it clear I was to have only one patient at a time. So in 5 hours, I took care of two patients! Works for me - I get paid whether I see pts or sit around twiddling my thumbs. I try to keep busy at least looking at xrays, going into rooms to update pts, etc..
That's pretty amazing. I guess I don't understand why they are willing to pay someone to do so little. Do they really think that midlevels are incompetent or do they just worry about losing their control?
The docs at the ER's where I work WANT us to see all our patients and theirs too! That way they can sit around and surf the internet. Obviously, we have to ask questions when the patients get over our head, since not all the patients are true "fast track".
After you do the H&P on the patient, does the doctor come back in and recheck everything? Are you allowed to make a diagnosis or treatment plan without the doctor's approval?
At the moment (I'm on one month orientation), yes, everything is rechecked. Yes, it is a waste of time and $$$$. They assure me that they want to keep me and they will relax as time goes on. The doctor I worked with on Tuesday was the ER Medical Director for several years and sat on the credentialling board. He says that the company we work for now, can ask for a re-eval of privileges at any time so there is hope - lol!
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
That's pretty amazing. I guess I don't understand why they are willing to pay someone to do so little. Do they really think that midlevels are incompetent or do they just worry about losing their control?
The docs at the ER's where I work WANT us to see all our patients and theirs too! That way they can sit around and surf the internet. Obviously, we have to ask questions when the patients get over our head, since not all the patients are true "fast track".
After you do the H&P on the patient, does the doctor come back in and recheck everything? Are you allowed to make a diagnosis or treatment plan without the doctor's approval?
Hmmm, sounds like a good starting point.
Hang in there, do your job well and things will turn around for you.
from my personal experience, in my current ER practice, after 7 YEARS, I have about 4-5 MD's out of our group of 25-30 MDs that will NEVER go behind me pretty much unless I ask them to or if I'm unsure.
There still are about 2-3 however, who like me to present everything after my initial HPI and exam and before I start ordering diagnostics.
Most of the other ones just appreciate me presenting them just prior to disposition (IE after all labs, tests, interventions), just to put the "blessing" on them.
I think it just takes getting to know each one and working with them. Trying to find what their comfort level is.
I will say this, it is interesting when one of the "old guard" is working during double coverage with one of my "friendly MD's" and they see how me and the "friendly"MD's work together - I think they take notice of a difference in practice patterns.
As well, our MD's have some revenue bonuses attached as part of the billable RVU's, and yes, they do get some financial benefit from my work as in our state NP's are "supervised".....interesting but I kind of look at it like, "okay, i've got some pt's to check out, who wants the $$$$.....!!!!"
Keep your chin up, be professional, ask questions when necessary, if in doubt - consult EARLY, stick to the pertinent postivies and negatives only, treat your staff RN's kindly and eventually it will pay off!!!
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
Totally agree! Do you work in the main ER or the Urgent Care/Fast Track?
You couldn't have asked a more COMPLEX question..."yes" to all of the above and then MORE!!
I only do nights (7p-7a), here's how it breaks down...
7pm: Clock in, get report from the OFF-going midlevel that was working our CHF/OBS unit all day, do a brief assessment or two on those pt's and check on labs etc
7-8pm: Rest of this time is "admin", BUT I have to be available for any NEW pt's that need orders written to come from one of the main ER sections to the OBS unit (IE: write OBS/admit orders)
9pm: Relieve the 9a-9p MD who's been in Fast track all day
9p-1a: Work fast track, just me and a RN
1a: Close Fast track, go get "lunch" and then go across campus to make 'rounds' on our behavior holding pt's (they are still in ER status, but they've been medically cleared to await placement at various psych/detox facilities; sometimes 2-7 days wait!)
2am: Back to Main ER (Intermediate) to relieve the MD who worked 6p-2a. From 2am on, I'll remain in IMC with the MD who is doing 12 hours that came in at 7pm into IMC.
For the rest of the night I see pt's side-by-side with that IMC MD, we pretty much split the load.
Now of course, I have to STILL be available for any other CHF/OBS pt's that need admission to the OBS unit, AND, the NP's are part of our stroke team. We have to respond to all CVA's that come in and we work, then, in tandem with the Critical Care MD and/or the Neurologist if they come in! So sometimes my IMC pt's have to wait a bit.....
WHEW!
We are currently working on 2 more full time positions on the night shift so that we don't have to do so much double-duty. Our dayshift is covered with 2 mid-levels working 7a-7p and they split the responsibilities of CHF/OBS and Strokes, and the behavioral unit. And then if things are slowed up, they'll jump in and start seeing patients in either the IMC or the chest pain ER.....
ANPFNPGNP
685 Posts
Good luck tonight - I'm right there with you! I'm filling in for someone tonight from 5-9. I'll get to work 1 hr with that doctor who yelled at me - please say a prayer for me! I found out that another NP is no longer allowed to work at that facility specifically because she got into it with that doctor. Apparently, he treated her the same way and she wouldn't stand for it. Unfortunately, they chose him over her, so she's no longer allowed to work there.
Since 2006 this ER staffing company has required all their docs to be board certified in ER medicine in order to work in urban areas (those who already worked for them were grandfathered in). That doctor is an ER doctor, so it's not like they're going to get rid of him or even discipline him in any way. Apparently, it's pretty tough to find docs who are certified by the ABMS in ER medicine.