Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, December 17, 2008

Rant Time in the ER

An ER nurse who just doesn't get it:
I was sitting at work a couple of days ago and one of the other nurses commented that staff nurses could really handle a lot of what comes into the ER without doctors. It got me to thinking, why do we pay doctors big salaries to do what a nurse practitioner could easily do? Honestly I think that a nurse practitioner could easily handle what comes into an ER if they specialized in emergency medicine. My co-worker pointed out that they couldn't do emergency procedures. Why couldn't they? They could intubate, place central lines, etc. if they were trained. Nurses are already doing this in some places.

The thing about changing medicine and making it less costly is that there are so many interest groups that would fight it. Among the first would be the AMA which will fight it tooth and nail. I guess that is their purpose to stand up for doctors.

As I see it the future of medicine in primary care, family practice, is the nurse practitioner. Doctors will be the specialists. Will nurse practitioners change the face of medicine? Perhaps. Nurses are taught to look at the whole person. Doctors, for the most part, are taught to treat the physical. Nurses learn more about preventive care. Doctors, for the most part, learn to deal with problems that have already happened.

If you are a young nurse, consider being a nurse practitioner.
Oy. Here's my comment:
Why stop there? I've seen what nurses do in triage. They just ask a bunch of questions off a sheet of paper and do whatever the protocols say. It seems like the unit clerks could really handle a lot of what the nurses do. Why pay nurses big salaries to do what a clerk could easily do? Honestly, I think a clerk could do what a triage nurse did if they were given specialized training.

The thing about changing ER nursing and making it less costly is that there are so many interest groups that would fight it tooth and nail, like the ANA. I guess that is their purpose to stand up for nurses.

As I see it, the future of nursing is the clerks. Nurses will take care of people already in the hospital. Will clerks change the face of the ER? Perhaps. Clerks are taught to do paperwork.

If you are considering a medical career, become a clerk instead of a nurse or a doctor.

(Oh, wait: I guess we already are.)
When are people going to realize that watching someone do something does not make you qualified to do it, even if you think it looks easy? So much of what doctors do (and many other professions as well) is infinitely more complicated than it looks, especially when someone is very good at it. Just because an extremely skilled physician makes medicine or surgery look easy does not mean that anyone else "could easily do it," regardless of "specialized training" (short of medical school and residency training.)

This is as true for Primary Care medicine disrespected by Partialist physicians as it now appears to be for Emergency Medicine disrespected by ER nurses. I, for one, am getting really sick of it; so cut it out already!

(h/t to Scalpel)

(Note to all you ER folks: not talking about fast track or misuse of ERs for minor shit here, because hell, a clerk really could triage that crap. The question is, would you want them to?)


At Wed Dec 17, 07:02:00 AM, Anonymous Anonymous said...

In the UK, the NHS is already moving towards the "nurse as primary caregiver" model, purely as a cost-saving measure. It's cheaper to pay nurse practitioners.

Predictably, patient care is suffering, because the nurses are overloaded, and have top follow the paper protocols, with no opportunity to think outside of them.

Check NHS Blog Doc's archives. He does go on.

At Wed Dec 17, 08:07:00 AM, Blogger Ninja Pharmer said...

Why stop there? Why not have paramedics and EMT's run the ER? We can intubate, we could learn how to place a central line if we were shown how to.....I mean we are EMERGENCY medical provders. Where better to put us but in the EMERGENCY room?

I think that some nurses don't really know what medical school is like; they don't realize how much more involved it is compared to their training. Nursing and medical school are very, very different and I wish that more people understood that.

Gah. I wish I knew where that nurse worked so I could avoid the place like the plague.

At Wed Dec 17, 09:08:00 AM, Blogger Resident Anesthesiologist Guy (RAG) said...

It's part in parcle of the altererd views towards medicine these days. Too many people have been duped into thinking that protocols and cookbook thinking is the way to treat sick people. It's not. Woe be to the patient who is treated merely by a protocol following automaton who, rather than assessing and reassessing the validity of their treatment, will instead proceed without thought - falsely believing they understand medicine.

I see it a lot as well - many nurses questioning openly and in front of patients the doctor's order. It's poor form and one of the worst ways to destroy patient-phycian relationships.

At Wed Dec 17, 09:12:00 AM, Blogger scalpel said...

Well said.

At Wed Dec 17, 10:57:00 AM, Blogger Ambulance Driver said...

I worked in an ER for quite a while. I even had the luxury of writing my own job description.

As a critical care paramedic, my knowledge base was on a par with my nursing colleagues. For the most part, my skill set was broader than my nursing colleagues.

However, I don't have the chutzpah to suggest that my *formal* education matches that of a BSN.

And BSN's shouldn't really have the chutzpah to suggest that they can do primary care. Some things, yes. But by no means all.

This attitude is also a reflection of the root cause of the nursing shortage today.

There is no shortage of qualified nurses. There is only a shortage of people with nursing degrees who actually want to practice clinical nursing.

Too many of them want to carry clipboards, shuffle paper, bore people to death and call it education, or encroach on primary care.

At Wed Dec 17, 11:24:00 AM, Blogger Lynn Price said...

Dino, does that mean if I sleep at a Holiday Inn and watch Medical Discovery, I can be a doc too? Please say yes. Think of what it would mean to my writing career.

At Wed Dec 17, 12:11:00 PM, Anonymous Anonymous said...

Dont let a bad apple spoil your view. you put a clerk as a nurse and your Doctor license is at big risk of getting in hot water. Would love to see doctors and untrained clerks manage patients. What a joke of a post. This type of thinking is why healthcare in the US is a huge joke. Dinosaur is right!

At Wed Dec 17, 01:08:00 PM, Anonymous Anonymous said...

I'm an ER nurse and I totally agree with you. For 90% of our patients, I have an excellent idea of what's going on and what needs to be done. But we really rely on our docs to take care of the other 10% - I wouldn't know nearly enough about what I was doing. That said, our docs rely on US to get the easy cases started and keep things moving. It's a team effort, folks.
-whitecap nurse

At Wed Dec 17, 06:51:00 PM, Blogger LicensedToILL said...

I look at it like this: My NCLEX RN licensing review course was 2 weeks intensive. The review course for the MD licensing board: 6 weeks intensive. Do the math.

Nurses do good work. We do critical work. But we are in a weird place in the medical hierarchy where we aren't "as smart" as MD's but we are expected to gather pertinent assessment data, anticipate treatment, initiate treatment, problem solve, inform the MD of potential problems, and politely inform the physician when they write a wrong order that it will kill the patient- and do a fuck load of paper work on top of it all, and then take absolutely no credit for the positive outcomes but we always have something to do with the bad ones...
I think nurses get pissed because they don't get credit for keeping up with the MD's, which is our job, but nurses are inherently unprofessional so they talk a lot of smack about MD's and themselves.
In the medical field, pretty much everybody feels under appreciated as few people are.
Ultimately though, I agree. Following sepsis and MI bundles doesn't make one an expert on the disease process.

At Wed Dec 17, 09:36:00 PM, Blogger Jon said...

An exceptionally well trained RN is still not an MD. I'm not discounting their skills at all, but when I choose health care for me and my children, I want an MD treating us.

The times I've had to see a nurse practitioner, especially those in pediatrics, I've wanted to run screaming from the building.

At Thu Dec 18, 03:27:00 PM, Anonymous Anonymous said...

As a medical student going into final exams, I was frustrated to come down with a virus right before anatomy. The first appointment I could get was with the nurse practitioner in our school's medical center. My conversations/appointments with NP always seem to end the same way, with a resounding "I DON"T KNOW" on the part of the NP. Snot and clods they can handle, more complicated viruses in a type I diabetic patient are beyond them.
Then next day I went back and saw the internist, who correctly diagnosed me, ordered some more blood tests, and told me how long it was going to be before I recover. What I take away from this: ALWAYS SEE A PHYSICIAN - if you can...

At Thu Dec 18, 04:03:00 PM, Anonymous Anonymous said...

Even if Nurse Practitioners expanded their scope of practice, there still ultimately has to be a supervising physician. I would not want to be that physician unless I absolutely knew that NP and their work.

Conversely, if NP's became completely automatous, then they can bear the liability of their work directly and would really know why us docs are constantly CYA.

At Fri Dec 19, 08:04:00 PM, Anonymous Anonymous said...

A few obeservations: There is an obvious knowledge deficit when people are comparing the work of RNs to NPs. One does not become annointed an NP because they've been a nurse for x number of years or work in some busy ER. Maybe take the time to understand what the difference is before casting dispersions throuhout the profession.

Re: Anonymous 1:08, thats your health care dollars at work. See a real doctor, they order expensive probably unnecessary labwork and told you that you would recover. Wow, sounds like thats way different than your experience from the health center. Mad because you didn't get a Z pack?

Hashmd - there are ALREADY states that allow independant NP pratice. Actually, only a handful of states require "supervision" while the majority of states are collaborative practice or independant practice models. Oh, and they have fancy things like liability and malpratice to worry about too.

At Sat Dec 20, 02:58:00 PM, Anonymous Anonymous said...

Does anyone recall when D.O.s where treated like scum? I remember plenty of fellow M.D.s saying that D.O.s would destroy the title of "Doctor" or some such nonsense.
Its evolution. We need to meet a need. We have sick people who need to be treated. NPs that have gone to reputable schools* and have clinical experience prior to their masters level education can and do provide wonderful top notch care in Family Medicine and ER settings. Just like EVERY profession there are great NPs and bad ones. There are some Great doctors and then...there are god awful ones too. Should we discredit all doctors because a few we have run into have been horrible?
Family Practice doctors frequently seen patients to specialist because they dont know how to proceed or they start a course of treatment that a specialist deems unfit and they change it. Does that mean specialists get the right to say that family practice doctors have no idea what they are doing and should be abolished off the face of the earth?

When i first arrived in this dreary little PA town not far from Philly actually the majority of the Family Medicine doctors made my job much harder than it needed to be. So rather than whine, bitch, and complain. I invited them all to dinner and proceeded to tell them I wanted to work as a team to better OUR patients care. The big problem i was encountering was ordering unnecessary studies and strange medication combinations. ( the Prosti-Reps seem to be god here) The patients would be upset because they had to go back for more studies and where annoyed that i was changing their medications, after they had just paid some retardedly high copay. After that night i made several great friends,bettered the care of our patients and made my day a lot less hateful. Maybe instead of picking each other apart we could try and help each other? Teach, each other and maybe treat each other the way we ourselves would want to be treated?

* The one thing I seem to see that is holding NPs back from realizing their potential is a lack of standard education. The quality of NP that is produced seems to vary wildly from school to school. I employ several NPs to much success. I even hired one over a green doctor! GASP! And it wasn't about money either! What it boiled down to was how they interacted with the rest of the staff and the patients. I would even go as far to say the experienced NP could have danced circles around the newbie doc. Every interaction you have with another human being is a chance to learn or to share your own knowledge. Why let ego limit that exchange?

The over reliance on technology such as PDAs, or codebook medicine isnt just limited to Nursing school. Medical schools are doing the same thing. My son's histology and microbiology class doesn't even have them use microscopes. The attitude is that Doctors will be handed the results of studies so there for they shouldn't be bothered with learning more than what the PDA spits out at them. These kids will have fun in residency...

At Mon Jan 05, 07:15:00 PM, Anonymous Anonymous said...

So its July 1st and the ED is swamped with a school bus (full ) vs propane truck (driver and vehciel both loaded). Who will be of the most help, the newly minted MD's or the tired old nurses.

Best points made in comments are - every member of the ED team has the ability to be great or less so-How many ED staff trust everyone they work with? Less than 100% I am sure


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