Posts by Tracy Cardin

The Upside of Anger

Recently, I heard from a number of NP/PA providers in response to Dr. John Nelson’s editorial published in the January edition of The Hospitalist. In the editorial, Dr. Nelson refers to an article in the Journal of Clinical Outcomes. The single-site study compared routine versus expanded PA care in a community hospital, and the intervention group delivered a three percent reduction in costs with similar measures in quality. In discussing the results, Dr. Nelson concluded that this article showed that, with proper planning and infrastructure, care delivered primarily by PAs can go "OK". Many of you took offense at the lack of enthusiasm or support for the model studied and felt that it demonstrated poor understanding for the migration of roles for NP/PA providers in hospital medicine. So who is right? Was it merely one tiny study that showed “OK” results? Or was it an impactful article that demonstrates the…

The Inmates Are Running the Asylum

OK; that might be a bit of an exaggeration. But if you left your clinical shift asking why you feel so depleted and frustrated and why you had that negative interaction with that patient, you should do yourself a favor and read the recent review in the Journal of Hospital Medicine entitled "When Personality Is the Problem: Managing Patients with Difficult Personalities on the Acute Care Unit". In this article, it notes that about 4-15% of the population is affected by at least one personality disorder and that this prevalence is thought to be much higher in those seeking healthcare services – perhaps as high as 25% of the population. This is thought to be due to in part to lifestyle factors, such as drinking and drug use, as well as the fact that individuals who possess these dysfunctional personality structures may have difficulty accessing and utilizing care adequately. These…

Count Me – and My Intuition – In

In modern medicine, we’re surrounded by EMR systems, lab tests and increasingly complex medical equipment. But I sometimes stop and wonder: Where does my intuition fit into the equation? Case in point: The other day, I had one of those days that happens in hospital medicine where nothing goes right. A patient admitted right at change of shift, with a diabetic foot ulcer as a chief complaint, was found to have an 8.0-gram hemoglobin drop from her baseline. Further questioning by the night admitting MD revealed that the patient had been having melena for several days. GI was consulted, but the lab was considered to be spurious. A stat repeat CBC and type and crossmatch was ordered. The EMR system was down, though this was not apparent at first. Because of this, it was not immediately evident that the lab could not see the order entered into the EMR system.…

Pressure Drop

A famous joke in hospital medicine is Mitch Wilson’s oft quoted statement: “When you have seen one hospitalist group you have seen one hospitalist group.” It is true that there is much variety in comparing one practice to another. Maybe that’s why our specialty has such vigor; we are constantly trying to learn from each other and decipher and decode the problems in hospital medicine. But there is definitely one commonality in hospital medicine: pressure. We are pressured to take more patients and own more aspects of the in-hospital and post-hospital space. We are pressured to find providers, and that’s not easy to do in an environment where your neighbor might be offering more money or fewer hours to that treasured provider. This pressure on adequate and stable staffing is worsened by the shrinking reimbursements on the hospital side. A model where there is fierce competition for providers and shrinking…

Consider It Done

The VA health system recently sought senate legislation to empower nurse practitioners within the Veterans Affairs Department to practice independently, regardless of state-based limitations on their practice. This would allow all advanced-practice nurses (APNs) such as midwives, clinical nurse specialists, nurse anesthetists and nurse practitioners to practice without a supervising physician. Currently, 21 states, the District of Columbia, and the Indian Health Service allow APNs to practice independently. One of the primary motivators for this initiative was the critical deficit of access to care for veterans. Since this announcement, there has been a marshalling of forces on both side of this conversation. Physician groups, most notably the AMA, have denounced this plan as one that risks the lives and well-being of patients, stating that APNs lack the education and training to provide medical care and that there is no factual basis to establish that APNs practicing independently would deliver quality…
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