Shuttered

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I have had a number of nurse practicioner students come through my office over the years. I love to teach even though it is very stressful, patient satisfaction scores drop, and my production takes a hit. 

It is very frustrating, given this, to take on a student weeks from graduation who cannot tell me what is an appropriate oral antibiotic for strep throat or if an EKG is abnormal or not. Worse, they do not seem to care to learn.

After turning down multiple students so far this year, I finally agreed to take on another one a few weeks ago:

“What is your differential diagnosis for chest pain?”

Blink. 

“Tell me the current PAP guidelines.”

Shrug.

“What antibiotic would you choose for community acquired pneumonia?”

Blank stare.

“When do you graduate?”

In a month.

I realize that this may stir some controversy. Let me say that there are some really great nurse practicioners out there. I have met them. I have learned from some of them. There is a great role for NPs. 

Yet, each year the students I am getting sent to me seem less and less equipped to handle the responsibility they are about to assume. There is a wide range of skill level in physicians, too, but it is particularly frightening that these people will be wielding a virtual prescription pad in a matter of weeks. I get students from three different schools and it is not just one that is the issue. It is all three.

I am not sure I can keep doing this…

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116 thoughts on “Shuttered

  1. Interesting. And horrifying, but still interesting. What do you think is the cause? Or is it multiple causes? Is it that the education offered is inadequate or are they just passing people too easily?

    I’ll be honest – up until I read this, I thought that more NP’s could be a great force for helping to reduce healthcare costs – and they still might, if they kill all their patients!

    Morbid humor aside, it seemed perfectly logical to me that if NP’s can handle the more common, low-acuity, run-of-the-mill stuff (not unlike the Walgreens Take-Care clinics) that would free the yous of the world up for more advanced things or to say hi to more patients or to oversee a larger staff.

    Am I wrong?

    Liked by 3 people

    • First, doctors don’t really want to be freed up from head colds and such. That is a welcome break and it helps build a relationship with the patients. I think there is something wrong in the education process at these schools. Stay away from those pharmacy clinics, though. Seriously.

      Liked by 2 people

      • First of all, let me say as an ACNP- that’s Acute Care Nurse Practitioner- who worked as part of an intensivist team, I LOVE that you said this. I personally feel like I am a good NP, and I constantly study and learn. However, I have noticed a trend with people who are somewhat lackadaisical in their education.
        Also, I spent most of my time as a student with incredibly gifted teachers, who held me to a high standard. Or, maybe I held myself to high standard… either way. Here is the thing, those teachers were physicians and a select few NPs.
        I feel the education we get is completely on us. Did you know the current trend is online learning? And, it is very nursing oriented. I will never forget googling how to come up with a differential diagnosis.
        Another thing that is missing- is the formal rounding process- where you are expected to think on your feet, and respond in a group situation.
        I was lucky, the doctors I trained with, and then went to work for- love to teach during rounds. In some cases, it became almost a game. I was taught how to use Uptodate. I was taught how to read current guidelines for standards of care.
        I also had the benefit of a clinical pharmacist who rounded with us. My pharmDs taught me so much…

        Also, do you have any idea how ridiculously easy certification exams are? (This may be just me- again- I am not sure.) You can study a condensed outline of about 75-100 pages and do just fine. The questions are almost all procedural- and not really based in actual practice. I do ABIM practice questions just so I can read the rationales and learn. Pulmonary and CC board reviews? I love them!

        Another issue for me is the inability to have a lively conversation without people becoming offended. This has hampered my career in so many ways. I am not easily offended- and I welcome debate and challenging questions during rounds. (Just please don’t ask me about Starling…. I screw it up every time!) I have met many people who assume you are attacking them- and they shut down. Or complain. Or go tattle on you for being mean… Seriously????

        Another issue where I live- so many NPs are treated as scribes. Their physicians don’t teach them, coach them, or expect them to learn how to treat their specialties. They simply dictate H&Ps and DC summaries.

        Now, when I was first in clinical experiences- I was terrible. My preceptors knew I was brand new- and I did my best to learn quickly. I knew they were sacrificing so much to teach me. It also helps that I was able to hand pick people who knew me, and who were willing to teach me. This also held me accountable for doing a good job- or else I would be embarrassed.

        The model for educating NPs is flawed. It requires tremendous drive and tenacity to go above and beyond, and frankly it is difficult. Most NP students are still working full-time as nurses, and they have families. They are just trying to get through school.

        Now, all that being said. I think nursing as a profession needs to be held to a higher standard. I believe a BSN should be entry level for nurses, and I believe NPs should have to pass boards on a routine basis. I also believe CE should be more like board reviews.

        Another issue? There are very few fellowships for NPs. Everyone is so busy trying to get more independence for NPs- I believe the opposite. I should not be able to practice independently, I am a physician extender. There should always be a physician available for consultation when I am seeing patients. NPs and Pas do not replace doctors.

        Now, there are lots of crappy doctors too. But, that is a whole different topic.

        Thanks so much for openly sharing your frustrations. I feel them too.

        Liked by 11 people

      • I did not edit that! I’m sure it is barely literate… I feel passionately about this subject. We are certainly not all bad- and the best NP is not afraid to say when they are in over their heads. It’s about patient care, and not our egos… (I have a pretty big ego… But, I never hesitate to ask for help, or say I don’t know.) I’m afraid I am a minority in my profession though.

        Liked by 1 person

  2. OK Doc, now you are scaring me. Don’t fret though I am about to become 72, I know what to take for Strep, and pneumonia, what meds I get a reaction from and what I am allergic to. My generation can usually tell who are the idiots, but I am not to sure about the younger generation.

    When my daughter and my son had their first child each of them would call me for advice about what I thought it was. Regardless of what I thought I would tell them to take the child to the pediatrician. They have been lucky, they found really good doctors. :o) There are good young doctors out there, you just have to find them. I taught my children to question the doctors. ….

    Liked by 4 people

  3. I have had two very different experiences with NPs. The first one was great — a dermatologist, she wanted to biopsy a spot on my face that had been there for ages — it was melanoma. She got me into the best Derm Oncologist and a fantastic plastic surgeon. I was cancer free within two weeks and it was caught at stage 0.

    The NP in my gastroenterologist, however, is no longer allowed on my case. AT ALL. I had been having fevers — up to about 102 off and on for weeks. She kept telling me not to worry about it. I WAS worried about it. My boss, an MD, told me that I really needed to get a blood test to make sure there was no systemic infection. I called the NP and asked her to set one up. No, she said. “What you need to do is wait until your fever reaches 104 or higher, then go to the ER. That way they’ll process your blood test right away.” WTF???? You mean when I have sepsis?

    But then, I’ve had some pretty bad doctors, too. Like the one who, when I was hospitalized in 2006 for some sort of intestinal blockage, proudly announced that my x-rays revealed that there was nothing blocking my large intestine. “Maybe,” I responded, “That’s because I don’t HAVE a large intestine — it was removed in 1982.” “Oh,” said the doctor.

    Liked by 2 people

  4. High watermark of the present civilization? Sometime between Eisenhower and Nixon. Rome fell — only the vandals were outside the gates then, not inside the schools awaiting their Kardashian moment of fame and a ceo position.
    Sounds depressingly apocalyptic when you write it down in more than 140 characters.

    Liked by 1 person

  5. Have you talked to their supervisors or overseers Victo? If so, what do they have to say? The questions you mentioned seem to me to be pretty basic when treating the general population.

    Liked by 2 people

      • Is there a medical oversight organization that certifies teaching facilities, sets teaching curricula, and monitors graduates? Here there is a stringent testing process before nurse certification. As many fail as pass – or so I’ve been told. Could you make inquiries of the oversight organization?

        Absolutely when you train, it takes longer and if you have the same patient load, back-ups will occur.When we trained fuel drivers, the trainers were given a lighter work day and paid an extra premium for their anguish. Ha!

        Liked by 1 person

      • It’s not realistic for you to keep up production while training – no company with any matching program like yours expects that. It is not real – as I am sure you know. Best of Luck. ๐Ÿ˜€

        Liked by 1 person

  6. I agree with above that it’s both scary and interesting. I would think that NPs would be particularly skilled and dedicated. Do they have to have had particular nursing training and experience before becoming an NP? I know certified nurse midwives do. (I had midwives for both my pregnancies and deliveries, and also saw them for routine gyn care.) All of the NPs I’ve had contact with seemed to be really great. I wonder if skill levels also depend on state requirements?

    Liked by 2 people

    • Perhaps. I only see students for one state. NPs are often good. Some are terrible. Just like physicians. There is not a good way to tell until you get burned. Considering the responsibility NPs are given, I would expect a much higher level of knowledge starting out. They are not just going to quick clinics. They may not even realize the burden of responsibility they are assuming. I don’t know.

      Liked by 2 people

  7. Wow, Victo, this is a disturbing eye-opener! Seems the clinical ed system has failed the NP in many certificate schools today. So, you know I’m an NP (since 2000) who worked mostly in psychiatry. However, my internships in outpatient family medicine required that I know “something” about medicine! Your bad luck with NPs is so sad. It seems they make it through with no sense of practical clinical application. I’d be curious to talk to the school’s clinical instructors about this. Christine

    Liked by 2 people

  8. Over the years I had many student teachers and graduates who didn’t understand basic maths of English Grammar and had almost know concept of History other that what they had learned from Hollywood movies. And I could do nothing about it. Many of them, quite decent people, often said how amazed they were by my breadth of knowledge when I know that most teachers of my years assumed such a breadth of knowledge was a bare minimum.
    I can fully understand your frustration (and anger)

    Liked by 2 people

  9. That’s pretty bad. I’ve been lucky with the NPs I’ve had experienced with, add well add with the PAs. However, I’ve heard a lot of other experiences, too. I think they need to be required to have a lot more clinical experience before they graduate. I also think that the supervising physician should be able to nix the student’s progress if they don’t feel the student is ready to move in. It would also be good if they were required to be mentored by several different doctors with different styles and practices. If only the teaching institutes would listen!

    Liked by 1 person

  10. That’s really scary. Thankfully my first experience with an NP was a couple of weeks ago and she’s been so kind knowledgeable and helpful. She’s not fresh out of school either. She’s been at it for years. I’m sure that helps.

    Liked by 2 people

      • I like that. Knowing where to look seems key. When I was a union steward, sometimes I didn’t know the answer to contractual questions I’d get from people I represented. But I knew where to look, and I’d usually have the answer quickly. I like that this same method applies in medicine, and probably every other area of expertise.

        Liked by 2 people

      • You are exactly right Glazed. Just last night I was speaking with my nephrologist (kidney doctor) and asked about increasing the dosage of a drug for treating restless legs – a serious issue for some patients. He said he didn’t know but would look it up and came back 5 minutes later with an answer. That is fine with me.

        Liked by 1 person

  11. This is truly scarey for the future patients these now students will be treating. We don’t routinely see NPs in medical offices here – it’s more likely a PA. Every PA I’ve run into has been fantastic. My orthopaedic one knows more about me than my MD. Why are these students so disinterested in learning? Have they been led by their parents to believe they are so special and entitled that they don’t need to actually work?

    Liked by 1 person

    • One thing I hear a lot is that what doctors do is easy. I don’t think they understand how much they do not know. They don’t have fear. Fear is useful. It drives you to be better. They don’t have it.

      Like

  12. The worst reveal in your post is not the lack of knowledge, but the lack of caring. Why did they go into this field in the first place ? I’d like to think folks in any sort of health care are at least motivated by caring for others. Maybe I am naive. Sad.

    Liked by 1 person

  13. I have to chime in on this…. We have a few really terrific NP, DNP and ACNP staff. They are wonderful and extremely helpful and my best instructors….having said that… they are older and experienced, very experienced. We had one brand new NP for hospice and she is not cutting it. Too much pressure and work load.
    Now our new nurses….OMG….did they go to school…can they read? NO. We just did a spot edit today on some charts and the neglect is frightful. It is not a lack of knowledge. It is a lack of concentration, lack of critical thinking and just crappy work. We are letting them go by the boat load as they cannot cut it.
    I am an advocate for nurses in homecare be at least Bachelor prepared. Soon it will be a regulation and they may have to go to a Masters, especially for Case Managers. (Selfishly, I had to go through hoops to be a teacher and I was not saving lives.) I think it is the right thing to do. If there is nothing else about it, it make them work more in the process of learning, discovery and documentation. They also need to learn the business of homecare and health care in general. They come from the facilities where they bang out patients like a whore on Saturday night. l I also am a firm believer it is the generation and the lack of critical thinking skills. It is the system that produces them and we let it happen.
    What is very scary is that this will be the providers of the future. Makes me really want more alternative medicine. It has taken me over three years to get my basic certification in Healing Touch. You can get a nursing license in 18 months. Gee…..

    Liked by 1 person

    • I was wondering what you would have to say on the subject! I agree that there is generational issue going on here partly. The educational system has to recognize and adjust to address it, because we are failing these students and their future patients.

      Like

  14. I guess you are not the only one who will ask them questions. Will they get a job? Who would risk to give a job to such a person. It is not only their lack of knowledge, but the attitude. Scary ๐Ÿ˜ฆ

    Liked by 1 person

    • The problem with hiring someone in medicine is that you get a limited time to interview. Asking questions about clinical knowledge of an NP, PA, or physician is considered gauche and insulting. You don’t know what you are really getting until it is too late and once you have them, they are very difficult to get rid of…

      Liked by 2 people

      • HR should find the way. I agree that they cannot ask a professional question, but they sure have to know how to estimate the person’s general attitude towards work and responsibility.

        Liked by 2 people

  15. I can imagine! Standards are dropping all over the place. I once found that a nurse in Pre-op was taking informed consent for surgery from whomever was nearby, the patient’s friend, for example and in one instance, his landlord! They enter the OR with no idea about how to scrub properly. I’m not saying doctors’ standards are where they used to be a few decades ago either, but still…

    Liked by 1 person

  16. But ask the same student that doesn’t know their ceph drugs from cillins, about the narcotics and I’m sure they could prescribe anything from A to Z! Yet a pharmacist doesn’t have the right to prescribe….Sigh..

    Liked by 1 person

    • What I wish we could make is a hybrid of pharmacist and physician. That would be unbelievably awesome! There are so many drugs and so many interactions it is dizzying and difficult to stay on top of.

      Like

      • Yes–whatever happened to all of that super-amazing automatic drug-interaction Pharmacokinetics magic checking software that was supposed to happen? When I was still an I.T. nerd, that was in the planning–I would have thought it would be reality. The programming would be straightforward, and the data is the same data you doctors look up now. I don’t understand why any manual cross-checking is still being done.

        Are there no OTS (off-the-shelf) systems where you plug in the patient’s diagnosis/es, current meds, the proposed one, and it says “*** Danger! Danger! Danger, Will Robinson! ***”?

        Liked by 1 person

      • Too labor intensive to use an external program. I have a few times on some high risk patients, but it takes forever to input. Not practical in a busy practice. The EHR system we have does that to an extent, but you get it popping up with stupid alerts like “this medication contraindicated in chest pain”. WTF? It is nitroglycerin, of course it is indicated in chest pain! Not helpful at all. The new EHR we will be getting may be better at this. I certainly hope so.

        Liked by 1 person

  17. I rotated at a psychiatric residential treatment center for children during residency and several of the kids I saw came from rural areas where the closest child psychiatrist was 3-4 hours away and seeing a NP was the only local option. I’m not quite sure who was supervising them or whom the NPs consulted, but several of the kids were on the most ridiculous medication regimens i’ve ever seen (talk about poly-polypharmacy!)! I recognize there’s a shortage of physicians in general, esp psychiatrists, but i’m not sure whether it’s better to have no care or poor care! (And yes, there are many awesome NPs out there, whom i have the utmost respect and have even sought out for my own medical care! ๐Ÿ™‚

    Liked by 1 person

  18. Reblogged this on Actonbooks and commented:
    You kind of held out the hope that US medicine was somehow better — because of the money spent on aggressively interventionist diagnostics and treatment. Victo dolore says different and it’s mostly people that are the problem. But just to cheer you up, read the previous post, Happy Dance

    Like

  19. I have informed my doctor, and now my dentist, they are not allowed to retire until I no longer need them. And we know what must happen for that to occur. So here’s to THEM needing to work another 40 years. I do not want to go through this madness. I trust my doctors now to know, or to know when they must find something out.

    Liked by 1 person

    • Truly. It have terrible angst finding a mechanic and plumber and AC person that I trust. They can do terrible damage to your things and to your pocket book and disrupt your life so thoroughly. Doctors and dentists? Same thing. NP’s and PA’s? Same thing. I have the inside track and get to be privy to things others are not but if I did not, I just don’t know where I would start.

      Like

  20. On the comments about HR fixing this: If people really knew the regulations and laws of what you can ask in an interview, you would clearly understand how superficial it all is. There is no way to really get to the general knowledge base of a clinician until they are working. You can’t even ask their previous employer. It is all one big crap shoot. Those who are best at dazzling people in an interview are the ones who get hired and they are often not the best in the field.

    Liked by 1 person

  21. Between hiring professionals and offering apprenticeships (of some sort) you are forced to go for what works best for you.

    You can make a written test based on your experience consisting of frequently asked/occurring questions, cases and diagnoses for apprentice nurses as part of he application process for your practice. Let the candidate make the test on location, no (smart) devices or computer and only pen and paper.

    I do not know really. For some jobs I had mistakes were part of the learning curve but with people’s lives you want to really avoid mistakes. I hope you find a solution.

    Liked by 2 people

  22. I also think it has to do with the quality of the nurse you start with. I consider myself an excellent nurse and I am sure I will be a great NP. I am also a licensed psychologist and I am adding NP to my credentials. I have to jump though a couple of hoops, but I will get there. When I am done, I will be able to meet with people, diagnose them with a mental disorder and then, changing hats, prescribe something that will help them. And then continue working with them.
    Perhaps you could inquire to their supervisor in their current or last position…

    Liked by 1 person

    • Most of these are going straight from RN into NP without work experience. Perhaps that is part of the problem? Without having some experience in real life healthcare that is how they are not understanding the gravity of this responsibility.

      Like

  23. I know this post is about NP, so what I would like to add yes is on the same wavelength, but just different. When I was working in the SICU as an RN, we had rotations of new residents just fresh out of school every three months, who thought they knew everything. Scary thing is, they knew jack sh&t, and if it wasn’t for the nurses, those patients would not have received the care they did. When the rotation was done, those same residents were a whole lot smarter, or at least the majority of them were. I shake my head as I write this. And this was in the 90’s. I can only imagine how it is now. Just WHAT do they teach in school to these people who will one day be in charge of someone’s LIFE?

    Liked by 3 people

      • OH wow, Doc, my intention was not to get praise from you. I am covered in goosebumps. You’ve brought tears to my eyes. Bless you for realizing how tough an SICU is and what a nurse has to do in order to give the patients the best of care. It is downright scary and a lot of responsibility. Not only did the nurses (those of us who cared) have to know nursing, but medicine as well. You just made my day!!!! (((HUGS))) Amy โค

        Liked by 1 person

  24. I’m saddened and discouraged to read this post. from a nursing perspective, and it’s unfortunate you’ve had these experiences with np students.

    I currently work as an RN in primary care and I know the answers to most of those questions as a staff nurse, even though I’m not diagnosing. That’s shocking that they don’t know basic recommendations but more so, make effort to find out or read about it.

    Personally I work alongside some really awesome NP’s who are very knowledgable, thorough, and provide excellent patient care. My peers would be really lucky to have an MD supervising them who has your passion for teaching.

    Liked by 2 people

  25. I’ve noticed a parallel issue with nursing students that come through the hospital. They are nervous around patients, get tangled in monitor lines, and are shy to admit they’re two weeks from graduating and have yet to start an IV. (These are private university programs – Kessler, Hershing ) I hold them responsible for being negligent in arranging adequate clinical time – setting these kids for a tough couple of years.

    Liked by 1 person

  26. Well that’s mighty frightening! Sadly, I think there’s a sad demise among the new entrants to practically every career these days. And I don’t think it’s as much the students’ fault as their school’s. Not the teachers, necessarily, but the school administrators who, in their quest for funding, compromise what is emphasized in teaching one area for what might be considered “the greater good.” When my son’s fourth grade teacher wrote him a welcome letter to her class the summer before, and there were several spelling and grammar errors, I knew there was a problem!

    Liked by 1 person

  27. Loved this post. As an NP with a physician for a husband, I consider myself fortunate to have him as a resource–he was a better teacher to me during grad school than the NP’s were….. The schools ARE making it easier and easier for NP’s to graduate and go into practice. I also agree that NP’s in general should NOT practice completely independently-we are NOT physicians! We have a role, I don’t get the whole “we are JUST as good” argument. We don’t have that same education, period. The only good thing about NP’s practicing independently-as we may be soon be doing in Ohio–is that we are then releasing our collaborating physicians from vicarious liability, responsibility for a mistake or a bad decision made by an NP who chooses not to run things by the physician. I have seen enough to be afraid for the future of healthcare, I have seen why NP’s are often viewed as dangerous as a little kid running with scissors. As much as I hate to say it… we SHOULD have to pass boards more than just once in our lives, our CEU renewals are a joke… If we had stricter standards, there would not be so much opportunity for some NP’s to make the rest look bad.

    Liked by 1 person

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