ruralnurs

Yes I know that the term "midlevel" bothers many people. A CNM friend was once at a social gathering and introduced by a doc (that she felt she had a very good, respectful relationship with ) as a "physician extender". I think midlevel sounds better than physician extender. I guess I don't connect the term "midlevel" with "mediocre". In this situation and with the docs we are working I feel very respected and supported. They call us "midlevels" but there is no disrespect intended. Any suggestions on what type of service to call it? We will have one PA and two NPs.

CharmedJ7, Thanks for the response. It looks as if we are going to have a service where we will be given between 4 and 6 pts to be responsible for. We will still do rounds for some of the other pts and have responsibility for all the admision H&Ps. I think it will be pretty easy. I know there will be some tough pts but I don't think managing even 6 pts with a few H&Ps will be too much. It is a bit hard as the main physician is new (but amazing) and he has never worked with any midlevels. So it has been hard for him to relinquish control. He is pretty protective of the pts but I am Ok with that. He is a great doc and eventually he will see that we are a help to him. Ruralnurs

"I suppose one could refund their money if they do not Rx an ABX. This would satisfy the customer monetarily and increase trust in the clinic, but then the NP is not making the clinic money, and less business income means over time equals closed doors and unemployment lines." I realize that the above quote is highly unlikely but just want to warn that this type of thing would just be reinforcing the public's belief that they are paying for a script. They are paying for an educated, knowledgeable, experienced assessment and diagnosis NOT a script. If the assessment of nasal discharge and congestion revealed a tumor that had to be referred to a surgeon would you refund money because they did not need abx? No, you are being paid for your assessment and diagnostic skills, not a script.

Hi, I am currently working in an in patient psych unit and we are looking at creating a "midlevel service". I work with another NP and a PA. We have a hospitalist psychiatrist and the administrators are looking at ways to improve. Currrently the doc has responsibility for all the pts and we see the ones he requests us to, do some discharges and other things like all the admission physical exams. Has anyone been on a midlevel in pt service and have any suggestions? They are asking for input from us and none of us have any experience with this type of thing. Are you part of a service and see things you don't like? Things you wish they would change? This is an opportunity for us 3 to have some "say" into the creation of this and would like some thoughts if anyone has any. Thanks!

As mentioned in a post above, people are TRAINED to use the ED for primary care. I used to do ED and loved it and saw the same thing. If EDs used EMTALA the way it was designed it would eventually work. If a person come in for a non-emergency, like a sore throat or skin issue and they were triaged and seen by the doc and told, "You have XYZ and it is not an emergency and you need to follow up with your PCP" (and not give cough medicine or cream for the itch or whatever), eventually people in the community would slow down presenting for non-emergencies. However, it is behavior modification at its finest. I show up to the ED for a lady partsl yeast infection, even if I have to wait a long time, I get evaluated (must happen per EMTALA) and treated (not required by EMTALA of it is non-emergent). If I showed up and waited for hours and then told by the doc to see my PCP and I still got billed (even if I don't plan to pay) then I may start rethinking wanting to spend my afternoon in an ED waiting room. There are barriers to that however. I asked one doc I worked with why we didn't use EMTALA to our advantage. And this doc was one of the biggest complainers of when people would show up and wake him up for non-emergent stuff (and he was the CEO of the little hospital). He said it was PR, the hospital did not want the community to think badly of it. And he wanted to have good ER evaluations. So we can't really blame all the people that are wasting our health care resources by presenting to the ED for non-emergencies, we need to blame the organizations that encourge them by treating non-emergent conditions.

yelnikmcwawa, Thanks for your response. I just don't know if I buy it. I agree that all women should be given all options to them, but in my limited experience I just see our nation has become a people that want things easy and fast and with minimal work involved. I have given birth to 6 children, 5 with no pain meds all natural births and the 6th via emergency c-section (that I do believe was warranted). Having babies is hard work, anyone that has had a baby knows that. Our society has, for the most part, shied away from the tradition of working hard for things. My other specialty is mental health. One of the best evidenced based care therapies shown by research for anxiety and depression is Cognitive Behavioral Therapy. It is very effective for anxiety but what do most people in our nation want? They want Xanax or maybe Zoloft (or other SSRI). People choose to have bariatric surgery rather than do the work needed to lose weight. Take sleeping pills rather than practice strict sleep hygiene. Formula feed because they can easier give the baby to someone else (not all women formula feed for this reason I know). I am sure we can all think of things where we as a society has chosen the easier/faster way to attain what we want. I know that a c-section is not easier than a lady partsl natural birth (it was easily the worst thing that ever happened to me in my entire life). But women that have never had either can't fathom that getting some nice drugs and having other people do the work of cutting your baby out is harder than pushing your baby into the world on your own. They see that a scheduled c-section in convenient and won't be as painful (ya, bull%#@*). I know this is a rant but with the internet and movies like "the Business of Being Born" I have a hard time believing that most women that want to be actively and autonomously involved in their pregnancy and birth don't know what is available. Yes in my neck of the woods here there are little to no options for birth environment (tiny hospital, bigger hosp 80 miles away or homebirth with or without a birth attendant) and women may not know they can have a voice. Except when I was an RN at the tiny hospital I made it my mission to educate them, to give them a voice and a choice. I told them in the first few minutes of my CB class or when I first took over their care as their nurse that this was their birth and they get to decide most things. I was a fanatic and even my fellow nurses thought I was over the top with trying to keep things as natural as possible. Seldom did I ever see a woman choose not to have interventions. Sometimes it may be lack of knowledge but I think it is the way our society is going. I hate to see it and I hope that my 3 daughters all have the births they want, but what I wanted and what they may want may be different. I think we need to preserve natural and intervention free birth for women that want it. But rather than blaming the medical profession for women that want an intervention-laden birth, we need to recognize it for what it is. A choice.

This is somewhat dependant on the state you live in. A FNP has a very broad scope of practice, birth to death and in my state an FNP can practice in specialty areas (I have FNP friends that work just in mental health, obstetrics, pediatrics and ED). However in some states those areas would have to be filled by a psych NP, CNM, peds NP or acute NP. And even in my state there is a push for hospital based NPs to be acute care NPs. But really don't you think you should look at what you are interested in? For instance psych NPs are very sought after in many areas but jsut because you can get a job as a psych NP does not mean you would be good at it. You have do be doing some thing you enjoy. Usually if you loved being an OB nurse you will enjoy CNM, loved being a psych nurse, will enjoy psych mental health NP, etc. Good luck.

I was an RN at a very small hospital that did not do high risk OB, so the two docs that did OB really tried to keep things as low risk as possible. They DID NOT do elective inductions and God forbid an elective C-section. I seldom saw internal monitoring and the docs loved for us to have the woman out of bed moving and they both would deliver in any position the woman wanted. I loved OB and considered CNM but for various reasons chose a different APN role. I still visit this board however. I see so much complaint about (not necessarily in this thread) doctors and nurses taking natural birth away from mothers. This is true in many instances but we need to call it the way it is too. Many women do NOT want a natural birth. I have cared for so many woman that want an epidural at 8 months, they do NOT want to feel pain or discomfort, they want the baby to be born on its due date or even a pre selected date, they want the whole family in for the show, do not want to breast feed in the first hour because they need to go out and smoke, don't want to do to CB classes, don't want to have suggestions or instructions by nurses that really want to help, once they get the epidural don't want to even move as much as possible to prevent a c-sec,etc. I remember begging women to try the ball, try walking, try the shower, etc. I have been with the docs when they are arguing with a mom that just because her due date was 3 days ago does not mean the doc needs to induce right now. I taught the CB classes, they were FREE they got several nice gifts to include a nice car seat, we fed them and did everthing we could but they wanted the gifts then came up with an excuse to leave as soon as possible. My daughter's best friend from HS is 22 and now Pg with first baby. I offered to give her videos, talk to her, etc. She said her doc is trying to talk her into CB classes but she does not think she needs them, after all she believes in pain control so will get an epidural. So yes, the medical providers have taken natural birht away due to fear of lawsuits and convienence and power and control and whatever, but part of this is woman that want a medicalized birth. Just my thoughts........

Thanks for the input BCGradnurse. I think that one of the things I hope to put into the program is simple tips and pearls. I have read someplace (don't remember where) that about 70% of anxiety and depression is treated by primary care providers. So you are not alone and will probably continue to see anxiety and depression. And those two do have evidenced based guidelines. My pet peeve (and I may be getting myself into trouble here) is PCPs putting someone with anxiety on long term benzos. But I think one of the most important things is to not stop thinking like a provider just because someone has a mental illness. I have cared for a person that came in to our in patient unit after a suicide attempt and they had been seeing their primary care provider pretty consistently for increasing depression and after doing labs we found a crazy high TSH. The PCP did not even check! I have found so many physical problems in folks with mental illness that should have been caught (like UTIs in the elderly and medication interaction with polypharmacy) and may have been causing or exacerbating a mental condition. It seems like many providers see the mental illness diagnosis and stop looking any further. I think another important point is to know when to refer. And that is a hard one because there is not always someone to refer to, or the person has no $ or ins. I am glad to hear that you will have a psych NP available. Thanks for your view on things.

I drive 75 miles one way. If I am lucky and there is no snow or ice and the deer stay off the road I can do it in an hour and 20 minutes. If not it takes longer. I left a job that I could walk to in 90 seconds for this job and it is well worth it. I think to myself every day when I walk out the door, "I LOVE my job." I don't like the drive most of the time and I know this winter I will hate it but it is still worth it.

Thanks for the response Zenman. I do think that more indepth psychological disorder education as well as psychopharm. I feel evidenced based medicine is so important and so many non-psych providers (in my experience) don't do evidenced based care because they don't know it. thanks!

I was not sure how to name this topic. I am an FNP and just recently a psych mental health NP. I have been approached by the state university where I live to help consult on improving the mental health education of the non-psych (mostly family) NPs. I am very excited as I think that the psych portion of most FNP programs is minimal and I feel that many primary care providers are doing lots of psych and sometimes they feel overwhelmed or simply don't know what is evidenced based medicine and so don't provide optimum care. This is compunded by the fact that there is often not any mental health care around so primary care providers feel obligated (and we are glad they are willing to help). Also in the diagnostics area. I have seen primary care providers give a mental health diagnosis without meeting the diagnostic criteria, and then a person is getting treated for somthing they don't have and not getting treated for somthing they do have. Anyway, as non-psych providers or students, where do you feel there should be improved education? Also for any psych providers, wehre have you seen deficits that may be improved with better education? All info is appreciated. Thanks!

I looked for info on the NP section but found nothing so thought I would post here. I am an FNP and recently graduated with post masters psych NP. I have a great job that allows me two 5 day stretches off in a row each month. I am thinking of starting a very small independent practice open just 1-3 days per month. I mostly want to do it because I was working outpatient women's health in my community and many women are sad that I am gone. I have found a place I can afford. I don't believe I would hire anyone to help. I can do my own nurse stuff and appointments would be easy to make. I would specialize in women health, both physical and mental. However, I don't want to bill insurance. There is a program in my state called the Breast and Cervical Health program that pays for low income women to have free annual exams with PAPs and a mammogram. I can easily get on their providers list to accept these women. For other woman (not on that program) I want to be able to see women and give them a bill that they can send in while getting paid up front. I know there are more and more health care providers that don't bill insurance so know this is a possibility. I just can't find any info on how this is done (so the patient can bill their own insurance) such as do I just give them a receipt, do they need a copy of the medical note? I just think that billing insurance is a big pain and they often take up to 2 months to pay. I don't need to support myself, I am mostly doing it by request of my patients and I really enjoy this kind of medicine. My new job has me working in a hospital, also very rewarding but in a different way. In my state I can do this (need no physician collaboration) and can write scripts for any medication. I do have an NPI number as well as DEA, ect. I will also look into and get malpractice ins. Everything I find about NPs independently discuss a big private practice and discuss billing and coding etc. and I don't want that. I want small and pay for service type info. Any thoughts, ideas, resources, places I can get more info about NPs independent practice? I thought that nurse in entrepreneurial care may have some ideas. Thanks!

I recently graduated as an FNP in 2006 and just last week finished my post masters as a psych NP. I have had way more interest in me as a psych NP than an FNP. I wanted to work in out patient family medicine but got a much better offer as a hospital based NP in a mental health unit. Contact your SBON to see if you can find any psych NPs and talk to them. Call your local mental health center to see if they employ NPs and the VA usually hires lots of NPs. Nursing homes are contracting with psychiatrists and psych NPs as well as Hospice. That may depend on how independent your state allows you to be. Even some big ERs will hire a psych NP for the numerous psych patients that present. One of my preceptors focused most of her time with kids and she contacted a pediatrician and he hired her after she graduated. He loved having a psych NP in his practice for the kids he saw. Another classmate had been an OB nurse and got her psych NP so approached a big OB/GYN practice and they gave her a job doing referrals within their own practice. If you don't find something in your face, look for a job you can create. Good luck!

We have it in MT and NPs can sign for the "Green card" (as it is known here). http://www.flatheadbeacon.com/articles/article/whitefish_doctor_fined_over_medical_marijuana_clinic/17859/