Tired of FNPs

[ANESMCR]

This is anecdotal but I just had to vent. 
 

I’m at a foremost GI/Hepatology practice in my state. At least once or twice per week I will have a new patient dump come in on my schedule. I look at the referral which is almost always incomplete with a brief two sentence note. The patient is typically complex or high risk for endoscopy. The wrong labs are ordered. The wrong imaging is ordered. The patients are on inappropriate medications and doses. I’m therefore left to switch into internal medicine mode and mop up the mess as best I can and get these people optimized for what needs to be done. Whether it be endoscopy, appropriate labs, imaging, and referral. Even simple patients, like colon cancer screening or anemia, have had doubled down to tripled subsequent DNA stool tests completed after an initial positive, or are in an age demographic which is almost negligent to order similar type tests for no clear reason.

Note from an FNP yesterday for an 80yo male with choledocho, crazy LFTs, anemia with an INR of 9 on an inappropriate dose of Warfarin and possible liver Mets after a complex hospital stay at a system we do not service and had no idea prior to visit:

“Pt recently went to the ER for syncope. He had 3-4 units blood transfusion. He has gallstones. He says he was told he needs a colonoscopy.”

Doesn’t order labs, doesn’t review hospital visit w the patient. Literally takes word of mouth from an 80yr old with dementia then gets trigger happy with referrals. Of all things, an U/S is ordered…

Then I’m left with 5mins to review a brick of paper filled with CTs, MRs, labs, ERCP, etc. and get this guy on track, hopefully save his life from their Dr. Nurse.  
 

It is NEVER a PA. It is almost never an MD. It is ALWAYS an NP that does this. It’s not the same NP either. Always different. This has occurred over 20 times from different NPs within the last 6 months. I’m sick of it and convinced these providers seriously lack the ability to critically think. How do they not get sued constantly? How are they permitted to practice independently? Who knows. And yes, there are great NPs out there, bad PAs and bad MDs. But I almost never see it. Maybe 1 out of 10 knows what they’re doing. 
 

 

[sas5814]

There was a time when the majority of NPs worked and were trained in a specialty and they were pretty great at what they did. I did my OB with nurse midwives and they were very skilled and pretty tough taskmasters.

I think the profession is starting to see the "shake and bake" online NP phenom come home to roost. Combined with administrators who are just looking for the cheapest, easiest warm body it's a mess.

I know its an old anecdotal story but my wife is a RN and she has worked with a number of LVNs who got their RN online and immediately started NP school online having never touched a patient. There are too many people looking for what is easiest and fastest and its affecting quality.

One man's opinion. Your mileage may vary.

[kang1208]

Also seen one of the NPs placed "NPO including meds" order for central line done at bedside..

Edited January 28, 2022 by kang1208

[MediMike]

2 hours ago, kang1208 said:

Also seen one of the NPs placed "NPO including meds" order for central line done at bedside..

I'd give them a sandwich during the placement if it would keep them from squirming around...

[krisephillips]

I am finding a universal patient dump by primary care in general. Seeing patients without basic workups or treatment trials constantly.  Would like to blame it on COVID/short staffing/etc...but this predated COVID.  Upsetting since it delays care and increases costs since basic workup and treatment now has to be performed by a specialty. 

Edited February 14, 2022 by krisephillips

[SedRate]

4 hours ago, krisephillips said:

I am finding a universal patient dump by primary care in general. Seeing patients without basic workups or treatment trails constantly.  Would like to blame it on COVID/short staffing/etc...but this predated COVID.  Upsetting since it delays care and increases costs since basic workup and treatment now has to be performed by a specialty. 

Same even in the hospital setting. It is not often that an appropriate workup and exam are performed prior to specialist consult. Our ortho service gets called for every red and painful joint in the ED by residents, docs, APPs, other specialists, and hospitalists without anything more than an x-ray and basic CBC. No advanced imaging, aspiration, additional labs, etc. Trauma or ED calls about a fracture but can't tell us if there were any associated wounds nor that a proper neurovascular exam was performed... 

Edited January 28, 2022 by SedRate

[ventana]

I REALLY love the acute care NP doing out patients and the Peds NP doing full Primary care

 

I really wonder if the Doc's are letting the NP's hang themselves as they are now independent?

 

I readily admit I am part of a team and this past week I kicked a few things around with the doc's, as a team.

Didn't change my work up as it was correct but it is nice to bounce stuff off each other (and in my practice we all bounce it off each other)

 

Medicine is a team sport and I wonder if the NP have taken it a step to far......  The insurance industry will keep track of this and if their is an increase in claims they will be the first to raise rates..... and so on and so forth.

[Cideous]

It doesn't matter anymore the school that NP's go to.  They are not regulated like us.  An FNP can do anything.  All that matters is the word "Practitioner" in their name.  State regulators do not go after NP's for practicing outside of their "school of training"...you guys know that right???

Florida fell, California fell....Texas is next.  Full practice independence is coming soon to the lone star state for them.  Mark me.

[iconic]

3 hours ago, Cideous said:

It doesn't matter anymore the school that NP's go to.  They are not regulated like us.  An FNP can do anything.  All that matters is the word "Practitioner" in their name.  State regulators do not go after NP's for practicing outside of their "school of training"...you guys know that right???

Florida fell, California fell....Texas is next.  Full practice independence is coming soon to the lone star state for them.  Mark me.

YoU jUsT gOtTa PrAcTiCe EbM

[Cideous]

On 1/30/2022 at 5:53 PM, iconic said:

YoU jUsT gOtTa PrAcTiCe EbM

WTF?

[Hope2PA]

On 1/30/2022 at 7:53 PM, iconic said:

YoU jUsT gOtTa PrAcTiCe EbM

Can’t practice evidence based medicine if you can’t get an f-in job.  Fact is PAs are generally ignorant  in promoting profession, title matters to improve legislation. and  the business of medicine wants independent practitioners they  don’t care if NPs don’t know what EBM is. PAs have done a great job screwing the future while blindly believing all is fine. I overheard clinic scheduling ask patients, do you want to see Dr.X, practitioner Y, or Dr. X’s assistant. Why would I want to see Dr X’s assistant when I can see Dr or practitioner?

[MediMike]

3 hours ago, Hope2PA said:

Can’t practice evidence based medicine if you can’t get an f-in job.  Fact is PAs are generally ignorant  in promoting profession, title matters to improve legislation. and  the business of medicine wants independent practitioners they  don’t care if NPs don’t know what EBM is. PAs have done a great job screwing the future while blindly believing all is fine. I overheard clinic scheduling ask patients, do you want to see Dr.X, practitioner Y, or Dr. X’s assistant. Why would I want to see Dr X’s assistant when I can see Dr or practitioner?

Hope I see you post a lot on here about how poorly the profession is doing in your area. Would you mind telling me what field you practice in as a PA and the general geographic region?

[trazodone]

13 hours ago, Hope2PA said:

Can’t practice evidence based medicine if you can’t get an f-in job.  Fact is PAs are generally ignorant  in promoting profession, title matters to improve legislation. and  the business of medicine wants independent practitioners they  don’t care if NPs don’t know what EBM is. PAs have done a great job screwing the future while blindly believing all is fine. I overheard clinic scheduling ask patients, do you want to see Dr.X, practitioner Y, or Dr. X’s assistant. Why would I want to see Dr X’s assistant when I can see Dr or practitioner?

So why don't you become part of the solution and politely/professionally educate the staff member about your scope and role and the legal concerns about advertising an NP as a physician over the phone? Seriously. Let your interactions, ability to care for patients, knowledge, scope speak for itself. 

I used to love coming to this forum to help review contracts, provide advice, or simply hear about the profession in general. There's been a huge paradigm shift in the last 1-2 years. It's all doom and gloom. Complaining. Crying. This is not representative of what we do or the scope we have to care for our patients, nor is it representative of the profession. 

This forum has become a miserable place of whining and despair. Seriously. You don't lose weight by sitting on the couch. You don't quit smoking by keeping your lighter in your pocket. If you're so worried, take every opportunity you have with patients/staff/colleagues/NPs/MD/DO whoever to leave an impression on them, but DO SOMETHING! Attitude, both positive and negative are infectious. You're bringing everyone down. 

[CAAdmission]

39 minutes ago, trazodone said:

take every opportunity you have with patients/staff/colleagues/NPs/MD/DO whoever to leave an impression on them, but DO SOMETHING!

I think part of the concern is that we have depended almost forever on the strategy of wining hearts and minds "one patient at a time," when we really needed large scale advertising and advocacy from our big national orgs. What we have been doing is not working well. It does not mean we stop, but we need to add more layers on top.

[ANESMCR]

Just want to reiterate this thread was started to highlight blatant NP incompetence. Which PAs can do nothing to prevent.

[turnedintoamartian]

I have been fortunate to work closely with NPs at both of the practices I have been employed by. Each time they were RNs for a number of years prior to NP school and worked closely as part of a team. They have all been excellent clinicians and wonderful colleagues. They have all helped me in innumerable ways.

Yesterday my close NP colleague was lamenting the fast tracking of NP education that minimizes RN work experience. Every NP I have worked with has also been livid that RN experience is being pushed to the side as it was essential to their experience and education. It’s certainly interesting to see my colleagues be frustrated by the change but also verbalize preference for independence to some extent. None of them want to practice without physician input but on the other hand they do applaud the continued legislative changes. 

[iconic]

I don’t know.. some RNs really don’t care about learning the why behind thing and I’m not sure if decades of experience would change that. They need to tighten their accreditation standards however so that new grad RNs can’t just become providers with 45 credits and 600 hours of observation all while working full time 

Edited February 3, 2022 by iconic

[True Anomaly]

2 hours ago, turnedintoamartian said:

I have been fortunate to work closely with NPs at both of the practices I have been employed by. Each time they were RNs for a number of years prior to NP school and worked closely as part of a team. They have all been excellent clinicians and wonderful colleagues. They have all helped me in innumerable ways.

Yesterday my close NP colleague was lamenting the fast tracking of NP education that minimizes RN work experience. Every NP I have worked with has also been livid that RN experience is being pushed to the side as it was essential to their experience and education. It’s certainly interesting to see my colleagues be frustrated by the change but also verbalize preference for independence to some extent. None of them want to practice without physician input but on the other hand they do applaud the continued legislative changes. 

This has been my experience as well.  I work with multiple NPs who have all been NPs for >10 years, and had experience as ER nurses for many years prior to that- and it clearly shows because they’re all awesome.  And to a T, they all also lament the fast-tracking of these new-grad NPs who may or may not have some actual nursing experience prior to getting their NP.   

Our group won’t ever hire a new-grad NP, but at least they’ll consider a new-grad PA- even with prior healthcare experiences being weighted the same.  And as noted above, I think more and more practices are recognizing this

[Colorado]

I am still undoing the misdiagnosis of patients and missed diagnosis from years ago when my patients were in the hands of an incompetent NP. More a bash on her than the entire NP profession, but still.

Regarding the reference above about specialists receiving inappropriate referrals:

From a primary care perspective, I try to do as much workup and treatment as I can before sending to specialty care. Its also the nature of working with uninsured patients-we become their specialists to a point until they reach a point of being truly outside our scope of practice. I'm thankful for UCH doc-line in Colorado in which I can consult specialty care to help guide some of my workups and treatment plans prior to sending a patient down to them. A great example is rheumatologic conditions. At my office, we will examine, perform imaging/labs/biopsies, make the diagnosis, initiated first/second line treatments, perhaps a corticosteroid injection for certain conditions, maybe even start a conventional synthetic DMARD and only then, once we've "hit a wall" or are needing further treatment, do we send them on to rheumatology. (Or if they are complex from the start, sick, rare diseases I know very little about, etc)

This is one of those constant and worsening battles with patients. Increasingly they just see me as a referral mill. Like the rheum patient above. So often a pt comes in saying "Hey, Ive had this pain in my wrist and knees for years. I think I have rheumatoid arthritis and I want to go to the rheumatologist. Can you make a referral for me? Thats all I need today"

They make an appt. just to ask for a referral and when I explain that they should and can have initial workup with me first, they occasionally agree but more often than not they refuse and demand the referral. So either I am left telling them, no I will not place the referral (all hell reigns down from the patient to the clinic administration and then back onto me for Why didn't you place a referral when the pt asked?!) or I acquiesce and provide the referral (explaining that I offered to perform initial eval/workup but pt declined, insisted on referral). I really try not to place referrals without an initial workup but it happens. I see this a lot for dermatology and explain that I can work them up and get a diagnosis and treatment plan faster than waiting on a derm appt. which locally has about a 6 month wait list. Sigh. I have had better luck recently with telling patients there's a chance that if we dont do some initial workup in primary care, that their referral could be denied (which has happened and rightfully so)

[Cideous]

I see a NP as my Derm provider.  She's great.  No issues.  Very thorough and skilled.  We should all be very careful speaking in generalities about a single profession.  Incidentally I also worked with a guy NP in Urgent Care who had done a 6 month ER residency and he was great even with suturing.

Edited February 4, 2022 by Cideous

[kettle]

I too know some phenomenal NPs who work rural ER. I have seen a fair share not live up to expectations as well!

[EMEDPA]

17 hours ago, kettle said:

I too know some phenomenal NPs who work rural ER. I have seen a fair share not live up to expectations as well!

Yup, I have worked with a few rock star NPs over the years as well. Every single one had SIGNIFICANT prior experience in the ED or ICU (like 10 + years) and went to a real brick and mortar program, not an online travesty(and I refer both to NP and PA programs when I say this). I currently work with a 20 year ER/Flight RN who is going through an NP program. She will be a rockstar.

[roundabout]

I just spent the last month working with 2 separate FNP’s.

As nice as they are as people, they are lacking heavily in critical thinking and medical decision making. Just as you wrote, they take the patients word on everything and refer 99% of complaints to someone else. Not to mention some of the most lack luster physical exam skills I’ve ever seen. 

[ventana]

6 hours ago, roundabout said:

I just spent the last month working with 2 separate FNP’s.

As nice as they are as people, they are lacking heavily in critical thinking and medical decision making. Just as you wrote, they take the patients word on everything and refer 99% of complaints to someone else. Not to mention some of the most lack luster physical exam skills I’ve ever seen. 

yup they are seriously lacking in many aspects of knowledge in their first 3-5 years.  As well they seem to gain an "I am the doctor and don't question me" which is very comical as all the good MD/DO I know are open to questions and learning...

[ANESMCR]

Requested a plavix hold clearance for endoscopy on a pt recently. H/o CABG, PCI x7 stents on DAPT. It was being Rx’d by an FNP. Got the clearance back today telling us to hold his plavix for TEN flipping days……wtf.

To top it off, at the very bottom under the FNPs name header and credential, she took the time to literally hand write in “Autonomous Nurse Practitioner”