speciality NP's need your help

MissDoodaw · Jun 4, 2010

Hi I work in a specialty practice about 12 docs and 12 np's. MOst Doc's there are supportive of midlevels, not all are. Not much I can do about the ones that are not, they have been seeing articles hearing stories from journals and peers about how mid-levels are helping them to profit in practice, but it's a little trickier in specialty, to figure out how much I can do for them, easier sonce I am not the 1st mid-level, as time goes on though the holdouts see what I can do and respect my work and have become more collegial. I am not sure a phamplet will help.

I like having a doc to go to with those trickier questions so I can sleep at night, how much csf leakage is too much post cranipharyngyotomy in an outpatient? etc.....

Downside to this is it is absolutely putting yourself in a novice role, again. But it is a specialty practice. The NP's that have been there for 10+ years are still asking consult questions for the doctors, but less than I am after 1 year, that's for sure.

As for patients, those that ask for the Doc, I nicely say ok no problem, let me just get some information first and we'll bring the doc in...After I'm done, if they still want the doctor I will bring the doc in.

There have been a few in our practice that only want the doctor, physician explains that is not how our practice works, pt is nicely told they may want another practice....That was the practice's decision on how to handle such matters.

On the other hand in issues like biopsy results, or other test results w/ consequential results I porefer to have the doctor consult. The doctors prefer this also.

If I can close this note with my soapbox statement. NP's are certified by 2 different certifying bodies,regulated differently by different states, have different prescribing rules, very different education prerequisites, and curriculums,very different abilities, different priviledges hospital to hospital is it much wonder that doc's and patients are confused? Honestly, read through the posts on this board many folks that are posing questions that are interested in pursuing NP careers don't even quite get the role.

You will decide how you handle this issue, but if you are planning on staying on your practice, I would do whatever I could to foster professional working relationships with all my docs. Not saying I wouldn't leave a few pamphlets here and there in the lunchroom or ask the doctors to review this pamplet, wonder if it should be in the waiting room for pts to read to help clarify your role....

rnsrgr8t · Jun 4, 2010

I work in pediatric urology which is a medical and surgical specialty. I have 3 MD's and one other NP. I have been there 5 year and my colleague is the urology guru at my hospital and been there 15 + years. The attendings I work with are all on board with midlevels. Because 1/2 of the patients we see need surgical procedures or f/u after them, we tend to "share" patients. This is because some patients need interventions I cannot do (ie surgery). In clinic, we do work together in seeing the patients, the patients I know what the plan should be, I go ahead and start doing it after I get the history etc. Sometimes, I have no clue and let the MD do it after I get the history. I do have a subset of patients with voiding dysfunction I manage on my own but the patients know that ahead of time and know they are only going to be seeing me and are scheduled just to see me. Sometimes in a busy clinic and a routine follow up comes in and is scheduled with the MD.... if they are doing well and I know the plan... I will do the visit and tell them the plan and they can just f/u with me in the future or they can wait for the MD to see them...they often just want to f/u with me (I have the full blessings of my attendings to do this BTW). There are some diagnostic results I am comfortable to review and address on my own (urine culture results, adjusting some of their meds, reviewing some of the imaging we do) and I have the full blessings of the MD's to do this (I always keep them in the loop in case they want to change things since they have more expertise in the specialty than I do). I believe that I AM there to lighten their load in some ways...they could not see the volume of patients they do if I was not there.... but we work as a team. I always am quick to seek their input if I am not certain how to manage an issue and they always seek my input and value my opinion. You may want to have a meeting with the physicians you work with just to discuss their expectations and clarify what you are able to do. I have adjusted to working in a specialty very well and like that I have a backup at all times. The buck does not stop with me. :) It is different than primary care because you are working as the primary provider. In a specialty role, especially in a surgical one, it often has to be a team approach to work well. I still feel very autonomous and feel like I am using my skills well. Does that help?

core0 · Jun 4, 2010

Hi Everyone,
well i have made the leap from FP to now ENT...and need some advice. I am finding that I am like a student again in a speciality and the docs think that I am there to "lighten their load". I realize I am no specialist and will become proficent at my job in ENT soon enough but it is hard to go from calling all the shots in FP to being someone's load lightner. I have one doc that knows exactly what a NP does and she respects me in my profession and treats me like an equal however I have another doc that wants me to get the history on the patients and then he wants to do the rest and he is also the one that made a comment of "np/pa's are here to lighten the load of the doctor" I really had a problem with this statement. I need your help- i truly feel he is not educated about what a NP does or what our capacity is so would it be rude to sit down with him to give him some information of what we can do as NP's ( I have a great booklet about NP's) and what his expectations of me are so we can come to some common ground?
Also, as a NP specialist do you find that patients want the doctor? and when you come in they say "where's the doctor?"
HELP> Thanks, KJ

Welcome to specialty care. There are a number of issues here that you have to understand. The first is that the scope is different than with FP. In FP the scope and duties are similar to that of the physician. On the other end, for example surgery, an NPP will never have full scope and practice of a surgeon. ENT lies somewhere in the middle.

Next its good to remember the reasons that physicians hire PAs:

1. They have too many patients and need another provider.

2. They have an abundance of follow up appointments which prevents them from doing new consults/procedures which pay better.

3. They have enough people but they are staying every night until 9 or 10. The job is getting done but at a personal cost.

In the first case the NPP is usually used like any other provider with their own panel etc. The second two cases are more common in specialty practice. In both those cases yes, the NPP is their to lighten the load either in the consult/cases or from a personal point.

As a PA who was the first PA in the practice in my first two jobs it essential to demonstrate your value. There are number of ways to do this but eventually the physicians will have to work it out. While using you like the second physician does, does lighten the load, it is very inefficient and eventually they will figure this out or not.

My other piece of advice for being happy in specialty care is look for niches to work. For example 90% of HCV care in GI practices is done by NPs or PAs. This is an example of number two above. Time spent on HCV treatment is time spent not doing colonoscopies = >$1000 loss. PAs and NPs have become the experts in HCV treatment because of this.

In ENT allergy and asthma occupy a similar place. The patients are time consuming and offer relatively low reimbursement. One approach is to open a separate allergy clinic that will unload the regular schedule allowing you to prove your worth.

David Carpenter, PA-C