We have trained thousands of military personnel as battlefield medics who routinely performed emergency medicine and saved countless lives. Why can't we as a nation use their skills in peacetime as primary care emts or pas in some parts of our nation which would otherwise be without any medical care people. If they could do it under fire, think what they could do in peacetime. They would reduce the existing shortage of qualified medical care personnel if the laws and rules were modified to accept them.
2
I am an MD employee working for a massive healthcare conglomerate doing primary care in a large metro area for the last 20 years. I make about $15 dollars an hour more then the physician assistants I share patients with. I spent 8 more years in training then they did.
12
The hospital and physician/nurse models we have today have been inherited from the 19th century, when accurate medical information was rare (expensive to store) and especially visual diagnostic and imaging tools were simply non-existent. It is natural to cling to those traditions in matters of life and death. But considering the revolutionary role in diagnostics played just by telephones, photographs -- and much later by photocopiers and fax machines -- it should by now be obvious that we can develop more flexible, cost-effective methods to get basic care for average problems using all our resources. We build huge, gorgeous hospitals but is that actually what we need for the typical case of depression or anxiety-induced insomnia? What about for your average baby ear infection, adult sprained wrist, accidental cut, hygiene or nutrition problem, pregnancy test or a quick urinalysis?
1
Dr's practice is archaic. 1stly, telemedicine, teleheath,on-line devices, micro-blood analysis comes with better analysis that 90+% of the Dr's can make. And, for only a fraction the cost. They are steam engines in the age of diesel. I think ordinary college degree, and/ or military experience with some background/ training certification (with computer tools) should be more than sufficient for 90% of the case loads. Why do we need a Dr to read what the computer analysis is? And why are 50% of US docs schooled overseas, in such bastions of medical learning, R&D like Grenada? The guild system is alive and well.
2
Doctors chose the wrong profession . They should move on to places like politics where they can stop such dumb legislations.
Medical schools are brain drain .
Allow all masses to take online NP courses and a bit of a week and two on hand rotations here and there and here we go. Team is ready to treat innocent people independently .
Medical schools are brain drain .
Allow all masses to take online NP courses and a bit of a week and two on hand rotations here and there and here we go. Team is ready to treat innocent people independently .
10
I have had almost exclusively poor experiences with a variety of nurse practitioners. I find them to be overly aggressive (medically), too sure of themselves and unaware of their own limitations. Honestly, I don't really care if nurses "listen well". I want the competence and intelligence that battle tested doctors bring (and charge for). The writing is on the wall though - with cost cutting on the way pretty soon the only medical personnel I will be able to see on short notice will be a nurse practitioner. And that is a real shame.
19
The experience of practicing 36 years as a sub specialist taught me the most important component to the delivery of good health care is the art of listening.
The most highly trained physician who is distracted or with poor listening skills will provide poor quality medicine. Just providing the opportunity for a patient or family member to describe their problem provides 90% of the diagnosis. In my limited and unverified experience, the nurse practitioners are eager listeners and in most cases identify the issue or at least know when to ask for help.
The most highly trained physician who is distracted or with poor listening skills will provide poor quality medicine. Just providing the opportunity for a patient or family member to describe their problem provides 90% of the diagnosis. In my limited and unverified experience, the nurse practitioners are eager listeners and in most cases identify the issue or at least know when to ask for help.
7
It's funny that this article makes Ainsworth, Nebraska look like a town with no doctor and substandard medical care, with only a frightened nurse practitioner and a doctor who stops in once a month from another state.
Funny because my dad, Melvin Campbell, has worked as a doctor there for the past 37 years. He speaks highly of his NP, she's very capable -- and the only time she's on her own is when he's on vacation (that is, rarely). Yeah, the hospital has been trying to recruit a doctor since 2012 -- not because they don't have one, but because my dad can't work as the sole physician in the county forever.
In fact, he had a conversation with Ms. Tavernise when she was writing this article, which does shine light on the problem of rural communities with limited healthcare options. But come on. She wanted to make rural Nebraska look isolated, and doctors look like jerks, and the problem look scary for dramatic effect, and she had to ignore a few facts that didn't fit that storyline.
Funny because my dad, Melvin Campbell, has worked as a doctor there for the past 37 years. He speaks highly of his NP, she's very capable -- and the only time she's on her own is when he's on vacation (that is, rarely). Yeah, the hospital has been trying to recruit a doctor since 2012 -- not because they don't have one, but because my dad can't work as the sole physician in the county forever.
In fact, he had a conversation with Ms. Tavernise when she was writing this article, which does shine light on the problem of rural communities with limited healthcare options. But come on. She wanted to make rural Nebraska look isolated, and doctors look like jerks, and the problem look scary for dramatic effect, and she had to ignore a few facts that didn't fit that storyline.
36
Thank you very much for telling us the rest of this story that this author, apparently, conveniently left out. We all get lied to enough by these days by publications that want us to believe a skewed view of reality.
12
'Nurses' are not (necessarily) looking to seek role expansion; nurse practitioners are. Not all RNs with advanced degrees are or become NPs; one may also seek additional scholarly nursing training to become clinical nurse specialists, nursing researchers/PhDs, professors, public health leaders, directors of programs, etc. The AMA is *just* a bit misguided, undercutting the abilities and professional capacity of NPs - esp as we are willing to work in underserved areas. How has the medical profession proposed to respond to the massive numbers of the underserved? They certainly haven't been able to produce/sustain MDs willing to practice in these same areas, nor they offered suggestions of their practice might singly respond to the tremendous need. NPs do not - and have never claimed to - undergo the same training or education as MDs,' nor do we liken our roles to theirs. NPs undergo our own rigorous training, and are more than competent to assess, examine, diagnose, manage and refer patients with complex medical issues. We are conscientious, compassionate caregivers and health advocates uniquely poised to provide safe, individualized and effective patient care. Scientific research of patient satisfaction and outcomes has done nothing but support our efficacy AND sustainability. Patients trust us and know we truly care for them. The medical establishment is throwing their toys. This doesn't come off well, especially if we claim as our collective goal to care for PATIENTS.
8
If you can do it cheaper for the same quality, then it is a matter of economics. The decisions are made here by the MBA's of the corporate medicine world, and it has nothing to do with medicine, nor do they care - especially if you can't pay. In healthcare markets where there is no alternative to choosing a doctor, you get what you are given to. If NP's are it, that's it. You get what you paid for - or not through subsidies. These are the golden rules of the market, and as benevolent or passionate that healthcare may be of an industry, someone always pays if not you.
If you can do it better for the same price, then it is a matter of medicine, or at least being sold as such to the public. The public does not understand numbers, but they do want to feel good and patient satisfaction score is now the most measured metric for quality in the world of corporate medicine and will be used for widely marketing apples and oranges. Things are sold tend to be packaged, simplified, hyped such that snake oil can be a cure all. It gets you to buy in, to believe in the system. NP or MD are just a storefront.
I don't believe is really a matter of what tastes good (MD) or less filling (NP). Until this country can agree on the economics of healthcare, the insurance front (finance and policy) will rule over the service front (MD or NP). It doesn't matter who until we can agree on what and how to pay for it.
Tax increase anyone? I thought so.
If you can do it better for the same price, then it is a matter of medicine, or at least being sold as such to the public. The public does not understand numbers, but they do want to feel good and patient satisfaction score is now the most measured metric for quality in the world of corporate medicine and will be used for widely marketing apples and oranges. Things are sold tend to be packaged, simplified, hyped such that snake oil can be a cure all. It gets you to buy in, to believe in the system. NP or MD are just a storefront.
I don't believe is really a matter of what tastes good (MD) or less filling (NP). Until this country can agree on the economics of healthcare, the insurance front (finance and policy) will rule over the service front (MD or NP). It doesn't matter who until we can agree on what and how to pay for it.
Tax increase anyone? I thought so.
1
NP and PAs are fantastic as physician extenders and even primary/independent providers in rural settings. But let me tell you-they increase overall cost because they order way more tests and order more expert consultations for problems, a MD could have fixed. We looked at this data in our hospital and keep the PA , more as extenders. Another point mentioned, PAs are almost always, better trained clinically than NPs.
The average patient applauds when the doctor gets a boot and he/she now is seen by a NP. Right now there are no restriction on NPs to see a set number of patients-wait for a few more years and see what happens when someone who is minimally trained goes through 40 patients a day..
The average patient applauds when the doctor gets a boot and he/she now is seen by a NP. Right now there are no restriction on NPs to see a set number of patients-wait for a few more years and see what happens when someone who is minimally trained goes through 40 patients a day..
5
In 1927, Bertrand Russell said “The extent to which beliefs are based on evidence are very much less than believers suppose.” So, lets move from beliefs questioning the role of NPs to the evidence. And the evidence begins with the work of the late David Sackett, MD (yes, the father of evidence-based medicine). What does this have to do with NPs? Dr. Sackett was a lead author of the landmark 1974 Burlington randomized trial that showed NPs “can provide first-contact primary clinical care as safely and effectively as a family physician.” Notably, in 1974, and again in 2009, Dr. Sackett wrote, “the greatest impediment to wider employment has been an issue of economics, not efficacy.” Subsequent Cochrane reviews have found substantial evidence that NPs provide high-quality, cost-effective care, with outcomes comparable to, or better than, physician counterparts. As the NP role has been in place for 50 years, I think it is time to let go of “beliefs” and recognize the evidence that NPs and other advanced practice nurses do not require state-mandated oversight by physicians. NPs are then regulated by Boards of Nursing and assume full accountability for their own practice, as it has been in New Hampshire for decades. Removing the remaining barriers to NP practice in the US would be a fitting tribute to Dr. Sackett and honor the groundbreaking achievements of Dr. Loretta Ford, now 94, who, with Dr. Henry Silver, began the NP movement in 1965.
8
American medicine is on a downward trend . Doctors going to medical schools should consider other places as for sure will have disappointment having to be matche'd with high school drop out with GEd's
2
Dr Ford was so wrong . If he had opened more medical a schools where the wanna be doctors could also have a decent chance to shine their skills . Then there would have been a good pool of trained doctors. Nurses would stay nurses amd hell each other and technicians could do their jobs . But some how the gap was missed . Too little medical schools and many quakes ready to jump in .
While I admire Ms Osburn I would still not be willing to visit her for a medical emergency. Nurse practitioners are NOT doctors, they don't have the training and, dirty little secret, they don't have the smarts that doctors have to have. By all means allow nurse practitioners to do the day to day support work but do you really think that a nurse practitioner is qualified to deal with full scale medical emergencies?
6
Um, yes; we are. I ran a pulseless arrest code in my clinic a few weeks ago. The patient walked out of the hospital less than a week later.
9
Well, I trained then worked 7 years as a nationally certified, midlevel health practitioner.
Then, school, training and residency and testing to become board certified in my medical specialty.
The basic science education is missing in the training of a midlevel.
Now having that level of course work, and residency training, I am afraid do see quite a difference in my former thought processes vs now. And I can appreciate the difference in the kind of work produced by midlevels, and physicians.
Are midlevel health practitioners valuable? Of course.
Are they the same? Not in my viewpoint.
Then, school, training and residency and testing to become board certified in my medical specialty.
The basic science education is missing in the training of a midlevel.
Now having that level of course work, and residency training, I am afraid do see quite a difference in my former thought processes vs now. And I can appreciate the difference in the kind of work produced by midlevels, and physicians.
Are midlevel health practitioners valuable? Of course.
Are they the same? Not in my viewpoint.
8
I've been a medmal attorney for the last 25 yrs in CA. I only represent patients. In my work, I frequently see a vast difference between a doctor who has spent 9 yrs in med school and residency learning his/her craft and an RN who has gotten a 2-year degree from a community college.
I admit there are very experienced nurses, who have worked 15 or 20 years, who undoubtedly know a great deal about patient care, and can teach a young doctor more than a thing or two about caring for a patient. There are some nurses who also have deep theorectical knowledge regarding specific medical problems. But those nurses are relatively rare, while all doctors are expected to have both deep theorectical knowledge and excellent practice skills.
In general, medical error occurs either because of a “systems problem,” i.e., some break down in the system of care, or because of mistakes made, usually, by inexperienced doctors or nurses (though not always). But inexperienced, poorly trained doctors and nurses tend to make the most mistakes. Trial and error on the job becomes their “schooling.”
If a nurse or PA can demonstrate the knowledge and skills after long experience, 15 or 20 years, then unsupervised practice should be allowed in under-served areas. But for a serious medical problem nothing beats a well-trained, experienced MD who has a reputation for getting good results. That’s the best shot a really sick or injured person has.
I admit there are very experienced nurses, who have worked 15 or 20 years, who undoubtedly know a great deal about patient care, and can teach a young doctor more than a thing or two about caring for a patient. There are some nurses who also have deep theorectical knowledge regarding specific medical problems. But those nurses are relatively rare, while all doctors are expected to have both deep theorectical knowledge and excellent practice skills.
In general, medical error occurs either because of a “systems problem,” i.e., some break down in the system of care, or because of mistakes made, usually, by inexperienced doctors or nurses (though not always). But inexperienced, poorly trained doctors and nurses tend to make the most mistakes. Trial and error on the job becomes their “schooling.”
If a nurse or PA can demonstrate the knowledge and skills after long experience, 15 or 20 years, then unsupervised practice should be allowed in under-served areas. But for a serious medical problem nothing beats a well-trained, experienced MD who has a reputation for getting good results. That’s the best shot a really sick or injured person has.
10
Nurses are not doctors. Powdered creamer is not milk or cream. There are many fine nurses who do nursing, many good NPs who work with doctors to expand care. But the background of basic knowledge, the years of building a base, is not there. NPs practicing as "doctors" are not indeed doctors, and even in doctors' offices they may miss things.
The push for NPs is part of the dumbing down of America (no, I am not saying nurses are "dumb" (old term) or stupid).
Roughly 98% of obstetrical deliveries can be managed by a non-MD. But recognizing an impending disaster is what you want when the patient is any person, esp your wife, sister or mother. Multiple disasters have occurred by independent practicing non-MDs, whatever they wish to call themselves. There is a reason that MDs go for years through such rigorous training. Anyone can miss a diagnosis. But if a life is on the line even for 2% of cases, for them it is 100%.
The paper cited (NP/MD) covers a very small sample of patients, and only for two years; doesn't prove the point.
Uwe Reinhardt has been preaching about medical care from Princeton for years. He is concerned with cost, but I haven't found that he understands what practicing medicine is about. And so it is with HHS and insurance companies. BTW, they all pay doctors so little that doctors rush to make ends meet in many cases. Of course there are a few who stand out with their high incomes...for a few years. But the figures quoted in the comments seem fanciful.
The push for NPs is part of the dumbing down of America (no, I am not saying nurses are "dumb" (old term) or stupid).
Roughly 98% of obstetrical deliveries can be managed by a non-MD. But recognizing an impending disaster is what you want when the patient is any person, esp your wife, sister or mother. Multiple disasters have occurred by independent practicing non-MDs, whatever they wish to call themselves. There is a reason that MDs go for years through such rigorous training. Anyone can miss a diagnosis. But if a life is on the line even for 2% of cases, for them it is 100%.
The paper cited (NP/MD) covers a very small sample of patients, and only for two years; doesn't prove the point.
Uwe Reinhardt has been preaching about medical care from Princeton for years. He is concerned with cost, but I haven't found that he understands what practicing medicine is about. And so it is with HHS and insurance companies. BTW, they all pay doctors so little that doctors rush to make ends meet in many cases. Of course there are a few who stand out with their high incomes...for a few years. But the figures quoted in the comments seem fanciful.
8
For most of the care, you can self treat. A competent medical assistant can be equal to a RN. A competent RN can be equal to a NP. NP designation is earned by going to a 4 year nursing school & getting a masters in nursing. NP provides mediocre care (aka protocol driven nursing care) & when they cannot diagnose & treat they will refer to a physician. so, a patient pays twice - once of NP's misdiagnosis & mistreatments & then again for a physician. NPs also order unnecesssary tests & exams (studies by insurance carriers have proven this.) So, a patient has to pay twice. This choice,however increases insurance costs( premiums, deduductibles, copays ) for all. As a patient, I want to go to a single provider to fix all my problems, - a physician. A Physician has the training, education, experience & problem solving skills to fix a health problem at the lowest cost & in the quickest time possible. This alphabet soup of providers is the primary cause for cost increases & complicated handoffs. Healthcare is not akin to Cable TV or Cell phone provider customer service- You call customer service & they keep passing the buck to solve a problem. I want a single source to fix my problem. Health care is not about being nice & faking empathy.Even cable TV customer service &Airlines talk about customer service, but they don't do anything to fix problems. Who provides my healthcare is very important to me & I vote for physicians.Least is best.
8
open as many medical schools as possible with highest score requirememts to graduate . That should create excellence in the field .
Otherwise open all that online NP courses to general public as my handyman wants pass it too.
The medical standards cannot be somewhere in the middle . It either will stay up or go down south like in Nebraska and 20 states .
Otherwise open all that online NP courses to general public as my handyman wants pass it too.
The medical standards cannot be somewhere in the middle . It either will stay up or go down south like in Nebraska and 20 states .
2
In a for profit health care system you get a glut of providers where you don't need so many and patients complain about the care they get, and you have huge populations who lack the most basic care, they often die of things that are treatable, but any health care they can get is often not affordable ( there are bottom feeder corporate entities in health care ).
Doctors, NPs are not the ones getting rich in this scheme -
until we decide CPAs and CEOs of insurance and pharma companies are not the people we should worry about - nor should they make health care decisions - the inequities of health care will prevail.
Doctors, NPs are not the ones getting rich in this scheme -
until we decide CPAs and CEOs of insurance and pharma companies are not the people we should worry about - nor should they make health care decisions - the inequities of health care will prevail.
6
If they're "just as good" as doctors, then why on earth did these doctors spend all those years and all that money on med school/internship/residency? Thanks, I'll take the doctor.
21
Those doctors were stupids. All medical schools should have IQ cut off if 104. Any one Above it should be sent to politics and other professions to avoid brain drain . The rest should be given choice to be trained as licensed technicians to fully train patients or wanna be nurse doctors , which ever is easy
I have been a nurse for 22 years and an NP for 5. I work independently in primary care for a large multi-site organization. My practice outcomes and patient satisfaction are the same or better than the physicians in my organization. For those who post about lackluster experiences with NPs, you are living in a dream world if you think there aren't incompetent MDs too. However competent NPs and MDs are the rule, not the exceptions. Also, those of you with the "well fine, let them get sued like MDs do" attitude, get over yourselves! NPs have malpractice insurance and face the same challenges that MDs do in terms of litigious patients.
9
In Ohio, ya supervising physician overlooks NP's work. The physician is bearing the litigation risk. not an NP.
7
Sorry, a NP is NOT a doctor. I live in one of the underserved areas of CA. I have been seen by various NPs and have always had to resort to driving 250 miles, one way, to go back to my Primary Care physician of many years. I know most people do not have that option, but relying on NPs falls into the "better than nothing" category. Seems to me we would all benefit if the AMA had a program where MDs could work off some of their med school loans by working in underserved areas for 5 years. Or maybe it should be a requirement before any MD is allowed to start a practice. I remember the time when MDs went into medicine to help people, not because they would become multimillionaires.
The other thing I found annoying is that when an NP is working for a specialist I was always charged a co-pay for seeing a specialist when I had not even see an MD, let alone a specialist. Seemed to me to be a rip off.
The other thing I found annoying is that when an NP is working for a specialist I was always charged a co-pay for seeing a specialist when I had not even see an MD, let alone a specialist. Seemed to me to be a rip off.
19
The National Health Service Corps provides loan forgiveness for providers (MDs, PAs, and NPs) who commit to two years of service in a medically underserved area. However, this is a flawed system. There is no retention of these providers. It makes much more sense to train members of the community who are already committed to staying in the underserved area.
1
It IS a ripoff, but do not confuse the predatory financial aspects of existing healthcare management with clinical practice of anyone--NP, MD, MSW, etc.
Sorry you don't have a good NP--or ANY primary care provider where you will need him/her if you get very sick quickly (which does happen to those of us who survive). You should check out what we taxpayers subsidize for medical and nursing training before you complain. Neither will meet our needs as US citizen getting older.
Sorry you don't have a good NP--or ANY primary care provider where you will need him/her if you get very sick quickly (which does happen to those of us who survive). You should check out what we taxpayers subsidize for medical and nursing training before you complain. Neither will meet our needs as US citizen getting older.
2
Unfortunately, there are very few of these slots available, and so very few students or residents in training are chosen for them. Also, the total loan forgiveness allowed is generally $25K-$35K/yr, plus taxes, for about 2-3 years. Although this is better than nothing, it's a small amount of medical school loan totals, which are easily ~ $200-300K + at graduation. It would be good if this program were expanded.
1
Nurse Practicioners are very capable and I see two (my family practice providers is an NP as is my Gyn). That said, they are not as broadly nor as deeply educated at MDs. From a compensation insurance payment standpoint they are as stressed for time and have the same 15 minute per patient criteria as MDs.
They may be the only bet and supported by telemed capability and computer assistance in diagnostics it is certainly better than no access at all.
They may be the only bet and supported by telemed capability and computer assistance in diagnostics it is certainly better than no access at all.
3
A real doctor should be trained enough to treat simple and complicated issues himself / herself and not send a train of referrals.
1
NPs and PAs do not receive training in pathophysiology. The significance of this is greatly underestimated. This results in them being unable to link different signs and symptoms along with lab and imaging results to a single cause and they end up ordering more tests and using unnecessary treatments because they do not have the skills, knowledge or training to put all the pieces of the puzzle together. MDs take long to train because this ability takes time to develop. I am consulted by NPs and PAs to help diagnose and treat patients that most MDs would manage on their own. NPs and PAs have skills that are essential (and appreciated) to the functioning of a healthcare team, but to think they have the training to replace a physician is incorrect. NPs and PAs are excellent communicators, but that is no substitute for dignostic or therapeutic abilities.
18
Perhaps some NPs or PAs are not trained in pathophysiology but I did spend a year studying the subject. I attended a top-rated NP program and have been told by numerous physicians I trained with as well as worked with that I was well educated and competent to practice. Although MDs (and DOs and DPMs) do have more training, please look into the training NPs and MDs do receive before making such a broad, inaccurate statement.
4
They do have pathophysiology in undergrad (or post-bac BSN) as it is a requirement for just about all nursing programs here in the US, but it is nothing compared to what a medical student has to study. So, the NP education, in my humble opinion, doesn't even compare to that of an MD who has completed a residency.
3
"NPs and PAs do not receive training in pathophysiology."
Huh? Where did you get this idea? I can't speak for NPs, but I can tell you that as a PA student, we sure did. This isn't to say PAs are equal to MDs or DOs, but what you are saying is just plain wrong.
Huh? Where did you get this idea? I can't speak for NPs, but I can tell you that as a PA student, we sure did. This isn't to say PAs are equal to MDs or DOs, but what you are saying is just plain wrong.
5
I received physically demanding training, in a city far from where I lived, and fractured my arm in the process. I went to a hospital emergency room later that day.
An X-Ray was taken, several physicians studied it, and found no damage.
I continued the training.
I returned home two weeks later and went to a physician’s office. The receptionist asked why I was there - I was feeling pain though the X-Ray didn’t indicate a problem. She placed the X-Ray over a light table and said, “Of course you feel pain,” pointing to the fracture. Treatment for fracture resolved the problem.
My experience is only anecdotal. I believe most physicians know more about medicine and medical care than do most receptionists and nursing staff.
A friend in rural Montana - most of the state - said, “When you feel the pain radiating down your left arm, relax and enjoy the view, you’ll be dead before help arrives.”
Rural living in this country often brings with it sparse health care. We may become embarrassed and improve our rural health care system.
Non-physician health care will be less expensive.
Think how inexpensive treatment by self-confident medical personnel extensively trained in shaking seed-filled gourds at patients could become.
Politicians searching for simple, cheap answers may become satisfied licensing gourd shakers and settle for this solution.
I don’t think choosing rural living justifies inferior medical care, even should it become legally approved.
An X-Ray was taken, several physicians studied it, and found no damage.
I continued the training.
I returned home two weeks later and went to a physician’s office. The receptionist asked why I was there - I was feeling pain though the X-Ray didn’t indicate a problem. She placed the X-Ray over a light table and said, “Of course you feel pain,” pointing to the fracture. Treatment for fracture resolved the problem.
My experience is only anecdotal. I believe most physicians know more about medicine and medical care than do most receptionists and nursing staff.
A friend in rural Montana - most of the state - said, “When you feel the pain radiating down your left arm, relax and enjoy the view, you’ll be dead before help arrives.”
Rural living in this country often brings with it sparse health care. We may become embarrassed and improve our rural health care system.
Non-physician health care will be less expensive.
Think how inexpensive treatment by self-confident medical personnel extensively trained in shaking seed-filled gourds at patients could become.
Politicians searching for simple, cheap answers may become satisfied licensing gourd shakers and settle for this solution.
I don’t think choosing rural living justifies inferior medical care, even should it become legally approved.
3
I've known some very skilled NPs, but I'll confess to too little expertise to decide whether they can be as good as doctors reliably and with no supervision.
But that's not the choice that exists. It's not NPs or doctors, it's NPs or nothing. And there I'm absolutely certain that the nurses are better.
The real problem, I think, is that giving NPs license to practice will just expand the number of practitioners in desirable urban and suburban areas while the rural healthcare wastelands remain underserved. Well-trained nurses have little more desire to head out there than the physicians do.
But that's not the choice that exists. It's not NPs or doctors, it's NPs or nothing. And there I'm absolutely certain that the nurses are better.
The real problem, I think, is that giving NPs license to practice will just expand the number of practitioners in desirable urban and suburban areas while the rural healthcare wastelands remain underserved. Well-trained nurses have little more desire to head out there than the physicians do.
3
Stress fractures such as those induced by exercise rarely present on X ray during presentation. Unless the two doctors you saw were trained in Outer Mongolia, they should have informed you of this and also cautioned you not to exercise until the pain went away and/or to return for a repeat X ray should the pain persist. Your point is well taken.
4
WOW! Doctors won't like this change at all. While many of the laws and standards regarding the practice of medical care were designed to protect people, many of them also got turned into law through the intense lobbying of the Medical profession with the primary purpose of restricting access and keeping resources scarce so that prices can be kept higher. It happens over and over in many profession. Look at what Uber has done to the taxi business, and the taxi industry is busy fighting back by legally trying to restrict access. Its all in the name of protecting "The People" of course. We need to make sure you have a certain level of taxi, and it properly insured, and etc etc etc. I suppose 1 in a million cab rides that turns out to be important, so for that 1 in a million situation we added billions and billions to the cost, and make people's daily lives more difficult and expensive. And everyone gets a share of those billions that come out of the hide of the consumer.
2
It's high time doctors to change their professions or if too late ask the juniors to go to more satisfying professions that suits their potential and serve the country in a real way
Just like third world countries , there are many possiblities of technicians and nurses to practice medicine and no dearth of it .
Any one wants to avoid or by mistake gets too sick as a result of mishandled by wanna be doctor nurses , should be airlifted to Mexico for good treatment . End of the story
Just like third world countries , there are many possiblities of technicians and nurses to practice medicine and no dearth of it .
Any one wants to avoid or by mistake gets too sick as a result of mishandled by wanna be doctor nurses , should be airlifted to Mexico for good treatment . End of the story
How is it that a nurse practitioner with no formal residency or training in psychiatry, or any other specialty for that matter, can practice specialty medicine? The Nebraska medical board would not let me, a trained surgeon, practice psychiatry!
I can understand nurse practitioner's doing a simple general practice, but to grant them privileges to practice speciality medicine totally devalues medical school as well as speciality training.
As I recall, a formal psychiatry residency is 6 years, and that following 4 years of medical school. How in the world can can a 2 year nursing degree
be a practice equivalent?
This, "a little knowledge", is a dangerous thing!
I can understand nurse practitioner's doing a simple general practice, but to grant them privileges to practice speciality medicine totally devalues medical school as well as speciality training.
As I recall, a formal psychiatry residency is 6 years, and that following 4 years of medical school. How in the world can can a 2 year nursing degree
be a practice equivalent?
This, "a little knowledge", is a dangerous thing!
21
Doctor, it is good to know that you are ready to relocate to Wood Lake, Nebraska to fill in the gaps here!
Oh, you aren't? And your alternative suggestion is that the people there go without treatment altogether?
Oh, you aren't? And your alternative suggestion is that the people there go without treatment altogether?
6
She went through a psychiatric nursing program. But you are right an NP working on 15 minute per patient assembly line is as handicapped as an MD on 15 minute per patient.
3
There are specialities under the nurse practitioner field, specifically mental health, pediatric, women's, critical care, and family. Therefore they do their clinical rotation specifically in those areas, except for family NP, they are required to do certain amounts of hours and see certain amounts of cases in various fields. Also when an NP finished their training, they take the national boards in that field.
5
As an NP for the past 30 years I have usually discussed about 15% of my patients with the my collaborating doctor. Complex patients require teamwork to manage well. I don't expect any independent NP would set up a practice without arranging support by an MD (even on video) for the really difficult situations. The only reason I see an MD for my own primary care is that I can figure out most of my health issues on my own, so I need her for the hard stuff.
The reason I didn't go to medical school was because I couldn't afford it, in particular being out of the work force for so many years.
The reason I didn't go to medical school was because I couldn't afford it, in particular being out of the work force for so many years.
7
Most people cannot afford Medical School and doctors don't deserve to be sued for the mistakes of nurses. Unfortunately, this happens all the time! No excuses!!
With video hook-ups a partially trained person prob would be able to do tasks that a more trained person might otherwise do. Altho in all of this I do not understand WHY a nurse could not deal with a dislocation or insert a breathing tub -- (I thought EMS people could intubate if necessary.) Psychiatric therapy is offered by Social Workers after supervised experience. The issue of medication and mental illness has plenty of potential for problems -- no matter what the circumstances. Even/often MDs fail with psychiatric patients.
4
As usual, this discussion has devolved into nurses vs physicians competence and caring abilities. I appreciate the content of the article but nurses do nursing not doctoring - although some are prepared at the PhD or DNP level. Until we appreciate that all have valuable skills and may be no more "intelligent" than the other - as one MD ( offensively) commented- this discussion will go on indefinitely...and our patients will suffer.
5
When I was growing up, we had a copy of my grandfather's 1939 Merck Manual. I went to (3-year) nursing school in the early 1960's, and I think I had at least as much medical training as he'd had. Later, I practiced as an ARNP (anesthesia), and, as my husband said, years ago, the big difference between me and an anesthesiologist was "$500.000.00/year.
6
Was your grandfather a physician? And you seriously thought you were trained at least as well as him because you read his Merck Manual?? Are you serious?
Be afraid... be very afraid!
Be afraid... be very afraid!
12
The quality of nurse practitioners varies as much as any other medical professionals, but I've personally had so many bad experiences with nurse practitioners that I refuse to see them any more. A few have been well-educated and extremely caring, but I've encountered far too many who made major diagnostic mistakes.
The growing number of nurse practitioners mostly benefits the HMOs, not patients. The financial incentive is obvious: the HMO collects the same monthly payment, no matter who the patient sees. The nurse practitioner simply costs a lot less for the HMO to employ than an MD, so the HMO profits when we see a nurse instead.
The growing number of nurse practitioners mostly benefits the HMOs, not patients. The financial incentive is obvious: the HMO collects the same monthly payment, no matter who the patient sees. The nurse practitioner simply costs a lot less for the HMO to employ than an MD, so the HMO profits when we see a nurse instead.
19
I hear you. Same happened to me and even friends I know. I won't see anyone but an MD.
1
I am currently a student at Johns Hopkins School of Nursing enrolled in the BSN-MSN Nurse Practitioner program. I feel disheartened with many of the comments I have read on here: So many of the commentators are making assumptions and generating stereotypes about NPs based just on anecdotal evidence.
It is not a good idea to be stereotyping NPs or MDs based on our own personal experiences or biases. Of course, there is room for everyone to partake in the debate and share their stories. But in the end what we should base our decisions on is research and data. To this day, no one has ever tested whether or not an MD education is actually the most effective way to teach medicine. The same goes for NPs or PAs. So it is wrong for anyone or any institution such as the American Medical Association to be making claims that are not backed up by data. In the end, we should put to test all of these assumptions, and then let the data speak for itself.
It is not a good idea to be stereotyping NPs or MDs based on our own personal experiences or biases. Of course, there is room for everyone to partake in the debate and share their stories. But in the end what we should base our decisions on is research and data. To this day, no one has ever tested whether or not an MD education is actually the most effective way to teach medicine. The same goes for NPs or PAs. So it is wrong for anyone or any institution such as the American Medical Association to be making claims that are not backed up by data. In the end, we should put to test all of these assumptions, and then let the data speak for itself.
10
What data would you like? The data showing that Vanderbilt, et al, are handing out degrees to "nurses" who have no prior clinical experience, after a measly 4-500+/- hours of clinical training, usually by other non-physician providers? That's about 6 weeks of residency for a medical doctor. The average physician training involves over 20,000 (yes, that's right) clinical hours performed under duress, following patient care over 36 hours -- this is the way disease progresses, and it's well documented that continuing care provides the best education.
Would you be willing to undergo surgery by a professional who'd gotten their degree ONLINE?
Would you be willing to undergo surgery by a professional who'd gotten their degree ONLINE?
11
You hit the nail right on the head, kmc. I had neurosurgery a few years ago and I'll be diggidydoggidydoo if I would let anyone but a board certified neurosurgeon near me! I hope the day won't come when advanced care nurses want to perform surgeries.
3
Let's get real here.
There is not a PA or NP who would not rather be a Doctor. If they say otherwise, they are lying to you or delusional.
Why didn't they go to medical school? They didn't have the chops- plain and simple. Couldn't get in, or didn't even bother to try. Don't let the cost factor throw you- get accepted into a med school, and the military will pay for it in return for service afterward. A lot of very fine foreign medical schools are a fraction of the cost.
PA and NP training is nowhere CLOSE to that of physician training.
So right out the blocks we are dealing with a lesser "pool" of health care providers. There is no way around it. Testimonials to the contrary abound, but, as Lincoln famously said "Calling a nose a foot doesn't make it so."
Concerning any specialized profession, outsiders can make comments and observations, but they don't know what they don't know.
When choosing a primary care provider, it makes little sense to go with anyone less than the best qualified. It is a sad fact that a lot of clinics are driven by patient feedback. And negative posts on the internet can potentially ruin a career of any health care provider.
In a sadly perverse logic, the best way to get the "best" health care provider might be to ask people close to the clinic who the least popular internal medicine doctor is with the longest tenure. He or she has got to be very capable if they can survive and thrive in today's popularity contest driven medical climate.
There is not a PA or NP who would not rather be a Doctor. If they say otherwise, they are lying to you or delusional.
Why didn't they go to medical school? They didn't have the chops- plain and simple. Couldn't get in, or didn't even bother to try. Don't let the cost factor throw you- get accepted into a med school, and the military will pay for it in return for service afterward. A lot of very fine foreign medical schools are a fraction of the cost.
PA and NP training is nowhere CLOSE to that of physician training.
So right out the blocks we are dealing with a lesser "pool" of health care providers. There is no way around it. Testimonials to the contrary abound, but, as Lincoln famously said "Calling a nose a foot doesn't make it so."
Concerning any specialized profession, outsiders can make comments and observations, but they don't know what they don't know.
When choosing a primary care provider, it makes little sense to go with anyone less than the best qualified. It is a sad fact that a lot of clinics are driven by patient feedback. And negative posts on the internet can potentially ruin a career of any health care provider.
In a sadly perverse logic, the best way to get the "best" health care provider might be to ask people close to the clinic who the least popular internal medicine doctor is with the longest tenure. He or she has got to be very capable if they can survive and thrive in today's popularity contest driven medical climate.
11
I have been a nurse for over 30 years, and I have NEVER, ever wanted to be a doctor. Speaking of outsiders, you should not make statements about a profession you obviously know little about. Most of my nursing colleagues are awesome practitioners of nursing, and command patient loyalty some doctors would envy. Nursing is not medicine, thank God, and I'm very happy with it. The nurses in this article saw a need in their community, and are filling it. Thank God for them.
6
Never wanted to be a doctor. Never wanted to be an MD, that is. I did always want to pursue a PhD to learn how to do good clinical research. So now I'm a board-certified NP in two specialties pursuing a clinical research PhD. Love my career path and never doubted it for a second.
4
Then how come all these NPs want to do 80% of the SAME job (diagnosing, treating and prescribing) that MDs are doing? I agree with Steve. I know some BSN students and they told me that they want to be an NP because they do not want to wipe someone's behind! I was quite shocked.
In the '70s, I used to see a nurse-practitioner in the GYN department at Kaiser Permanente. After two years, she said that for my next appointment, I would need to see a doctor and I almost cried. She and another N-P led the Lamaze classes, and both were wonderful. I've since seen a much loved N-P at a general practice in Napa; when she unexpectedly passed away , the doctor (young, good but aloof) for whom she worked sent the entire practice an unprecedented letter talking about her.
I would gladly see a nurse-practitioner at any time for most ailments. No competition.
I would gladly see a nurse-practitioner at any time for most ailments. No competition.
5
Twenty-one states and DC have now passed full practice authority for nurse practitioners, which means that state legislators are embracing some of the recommendations from the Institute of Medicine to bring health care into the 21st century. Nurse practitioners are filling critical access needs not just in rural states, like Nebraska, but also with underserved populations, particularly Medicaid and Medicare beneficiaries. Whether an NP practices in primary care or specialties, like pediatrics, their academic and clinical training, makes them highly qualified. They are licensed by the state and have years of education, certification and nursing practice before entering an NP program. Just because an NP’s training is different from a physician’s does not mean the care provided is substandard or inferior. In fact, as many writers have pointed out, the care is frequently superior because their holistic perspective is vastly different. In health care today, the key is to work as a responsible team and focus on the patient. Cate Brennan, MBA, CAE, Executive Director, National Association of Pediatric Nurse Practitioners (NAPNAP)
8
I would not be looking for "holistic" if I were seriously ill. I would be looking for an MD with all the training and residency required to achieve that license.
1
More than 90% of a family doctor's patients will heal with or without the doctor's help. The important thing a "gatekeeper" medical person can do is refer the non healers to a specialist.
2
Here, Wally, is a very important statistic driving heathcare expenditures and patient suffering that too many ignore or never even knew. Grounded, educated, experienced common sense gatekeepers, whatever their advanced degrees, can change the system.
1
I did family medicine for a year and switched into psych for this reason. Primary care is a total grind. NP's give you time and are nice and loved, because they HAVE more time and when you don't have the stress of your loans, and being sued, and doing all the paperwork, etc. then you might smile more too. Doctors are only human. There is a reason that their levels of suicide and drug abuse are sky high compared to the general population!
If you want doctors in primary care areas, the government should stop cutting loan-forgiveness programs, which incredibley, continues to happen. Also, tele-medicine and tele-psychiatry are new and upcoming fields. No one should be devoid of access to healthcare, and I support NP's, but I'd be terrified to have an NP be my primary care doctor (as a doctor). Let alone psychiatrist. If it's that versus nothing, something is better than nothing. If NP's want to deliver care to rural areas, bravo to them. They should also be 100% responsible for the complications they will inevitably cause, and will feel the joy of having a bullseye on your back in terms of lawsuits. OBGYN malpractice is HUNDREDS of thousands of dollars a year in some states. Have fun and welcome to the club :)
If you want doctors in primary care areas, the government should stop cutting loan-forgiveness programs, which incredibley, continues to happen. Also, tele-medicine and tele-psychiatry are new and upcoming fields. No one should be devoid of access to healthcare, and I support NP's, but I'd be terrified to have an NP be my primary care doctor (as a doctor). Let alone psychiatrist. If it's that versus nothing, something is better than nothing. If NP's want to deliver care to rural areas, bravo to them. They should also be 100% responsible for the complications they will inevitably cause, and will feel the joy of having a bullseye on your back in terms of lawsuits. OBGYN malpractice is HUNDREDS of thousands of dollars a year in some states. Have fun and welcome to the club :)
14
This is all part of the coordinated effort to lower our expectations to Obama's levels. High unemployment and declining median wage? Deal with it - it's the new normal. After a few years you won't even notice it. Now Obamacare is driving doctors out of their practices with its low pay and red tape, but the spin apparently isn't that it's bad news. In fact it's great news we'll just give you these new people who are sort of like doctors but not exactly the power to treat you and everything will be fine. We'll also import foreign doctors who speak terrible English from questionable medical schools all over the world to set up medical practices in our country.
7
Some very fine doctors come in from India; some of the best.
1
nurse practitioners aren't the only threat to Doctors' fiefdom of diagnostics.
algorithms will eliminate humans from the diagnostic equation completely
algorithms will eliminate humans from the diagnostic equation completely
6
At least there used to be a program for doctors to pay off medical school debt (or some of it) by serving in underserved areas. Might be a good idea to expand it. It sounds very self-centered for docs to get in a snit about NPs without presenting a viable alternative which forgiving med school debt via service might provide.
Another idea would be to recruit among local schools in these regions and promise to provide forgiveness of debt for service among kids who come from the aea and are accustomed to what seems to those of us who grew up in more populated areas a bleak existence. The kids from the area are probably used to it and don't see problems with it.
Another idea would be to recruit among local schools in these regions and promise to provide forgiveness of debt for service among kids who come from the aea and are accustomed to what seems to those of us who grew up in more populated areas a bleak existence. The kids from the area are probably used to it and don't see problems with it.
4
I think they do this in one county in Maine, EKB. There must be others. Although I'd like to see it expanded (and I think it still exists) on the federal level rather than state-by-state. My mother had a friend who's daughter landed in a hospital in San Francisco; they were all from Massachusetts, SF's city hospital was where the need was at the time. Not all interns want to work with the destitute (although surely new doctos get excellent training that way - and a dose of compassion - I once had a wonderful experience with a resident at the old Boston City Hospital, I think it's called something else now).
1
The author had a golden chance to write a well balanced article, but she let her bias get the better of her. too bad.
The reason Nurses are moving into providing care is because of doctor shortage. This move does not solve the issue it just compounds it. Soon there will be a nurses shortage as more nurses opt for the lucrative field of "doctor".
Insurance companies and hospital CEO's love NP's as they cost less thus making them more money. And politicians are pushing for legislation, because the insurance lobby pays them to do so.
Had the author bothered to go undercover and go to clinics run my NP's and addressed them as "Doctor", she would have found that very few NP's would have corrected her. this is a serious violation of trust.
There was a time when doctors "listened" to their patients as many NP's here claim they do and are therefore "better". That was before doctors realized that they got paid for quantity and not quality, and adjusted accordingly.
Many NP's are currently salaried and don't have the incentive of quantity. Once that happens they too will stop "listening".
Health care standards in this country will soon go from bad to worse. Why should someone bother to go to medical school., when they can go to a nursing school, become an NP and make a 6 figure salary with half the hassles.
The reason Nurses are moving into providing care is because of doctor shortage. This move does not solve the issue it just compounds it. Soon there will be a nurses shortage as more nurses opt for the lucrative field of "doctor".
Insurance companies and hospital CEO's love NP's as they cost less thus making them more money. And politicians are pushing for legislation, because the insurance lobby pays them to do so.
Had the author bothered to go undercover and go to clinics run my NP's and addressed them as "Doctor", she would have found that very few NP's would have corrected her. this is a serious violation of trust.
There was a time when doctors "listened" to their patients as many NP's here claim they do and are therefore "better". That was before doctors realized that they got paid for quantity and not quality, and adjusted accordingly.
Many NP's are currently salaried and don't have the incentive of quantity. Once that happens they too will stop "listening".
Health care standards in this country will soon go from bad to worse. Why should someone bother to go to medical school., when they can go to a nursing school, become an NP and make a 6 figure salary with half the hassles.
14
I am a Family Nurse Practitioner with 25 years of experience. I graduated from Yale University School of Nursing with honors. I then did a three year, full-tilt, family practice residency program where ALL of my attendings were Family Practice Physicians. I had hospital privileges. I recently diagnosed someone with a very rare tumor. Another with a significant endocrine problem that 5 physicians has missed. The moral of this story? There are excellent physicians out there and then there are those who really do not like it, do not want to keep up and are awful clinicians. There are excellent NPs out there, but these are the ones that recognize the complexity of the profession and are smart enough to do a residency...as call it whatever you want....at the end of the day, you will be expected to be able to function just as a physician functions. So what are the advantages vs. being a physician? Well...for one thing, we DO have carte blanche to specialists. I have worked with specialist physicians all over the USA and never feel embarrassed or inadequate when I do. They never talk down to me. Many of my physician colleagues are NOT so willing to seek specialist advice...and as a result, the care of the patient is NOT what it could be if they did. They are "trained" to believe, they can do it ALL! So.....who would YOU rather see?
12
To get into medical school, I had to major in chemistry -- one of the toughest at my university--and get near perfect GPA, and then get MCAT scores in the 90 percentile, which required hundreds of hours of study. I didn;t party in college unlike all the other nurse majors. then 4 years medical school and 4 years intense residency.
And step one exam (8 hours), step 2 (16 hours) and step 3 (8+ hours), and these nurses have some online degree and are equally qualified? LOL, you should talk to a nurse and see how ignorant most of them are, if u want to put on your life on the line to support some female empowerment program that is fine, but i only trust doctors, thank u very much.
And step one exam (8 hours), step 2 (16 hours) and step 3 (8+ hours), and these nurses have some online degree and are equally qualified? LOL, you should talk to a nurse and see how ignorant most of them are, if u want to put on your life on the line to support some female empowerment program that is fine, but i only trust doctors, thank u very much.
18
I knew someone in Boston who majored in Art History and got into BU Med. He's now one of those doctors that news shows call on for opinions. He did very well in med school but had to take make-up lab courses before applying. Not an entire degree, just a few classes.
1
Congrats Luke. Glad you did not waste your time partying. Unfortunately, from what you wrote I only know that you have a high pain tolerance, no idea how good a physician you are. Also, I didn't get the female empowerment comment. Aren't there a growing number of female physicians?
2
Doctors are all men, nurses are all women? When did this happen?
1
The doctors are fighting a losing battle, not only is their alternative having insufficient primary medical care in some areas, there is nothing wrong with delegating a discreet area of treatment to those qualified to administer it. 90% of what walks into a family practice doctor's office can be treated by less than a physician's qualifications, correct?, so as long as they know where the line is to refer a case it is a win-win situation for everyone. It is no different than allowing paramedics to do this that and the other thing.
The irony is that the Nurse Practitioner community seems to practice the same discrimination, the same turf war, with the same arguments and probably the same motives against Physician's Assistants, who have the same skill-set as NPs but by education rather than by practice (as a nurse), yet are limited in most states to practicing directing under a physician. Authorize them both to practice independently with bright lines about when they have to refer a case to a physician, the collaboration will result in more service in under-served area and less expensive medicine for everyone.
The irony is that the Nurse Practitioner community seems to practice the same discrimination, the same turf war, with the same arguments and probably the same motives against Physician's Assistants, who have the same skill-set as NPs but by education rather than by practice (as a nurse), yet are limited in most states to practicing directing under a physician. Authorize them both to practice independently with bright lines about when they have to refer a case to a physician, the collaboration will result in more service in under-served area and less expensive medicine for everyone.
6
There is a study done in Arizona where NPs have independent practice as to practice location of NPs. It looked at zip codes of practice location. Guess what they found....... They were located in the areas of greatest population. Show me the money! In our area they practice where the salaries are the highest, with a specialist. Few set up in a rural setting unless sent by a hospital or federally funded healthcare facility. No altruism here.
2
Physician suicide rates are greater than that of any professional group in the US. Over 80% of all doctors would not recommend practicing medicine to an interested student. Physicians speak of decreased autonomy, increased paperwork, restrictions imposed by non-medical people interested only in money, and amazing levels of stress. Burnout is rampant, especially among high-touch fields like emergency medicine.
There's a 1 in 10 chance your doctor has seriously thought about killing himself because of the stress of his job. Yes, this is above everyone else in any high-risk field except the military.
Yet somehow, somewhere, the American public has become convinced the doctors are all greedy bastards who work 40 hour weeks and drive around in fancy cars. Somehow, it is the doctor's fault. NPs and PAs are honest, good, true professionals. Doctors are just in it for the cash and prestige. Doctors don't care. Doctors are in the pocket of big pharma.
Why go through that sort of hatred if you don't have to? A 2-4% suicide rate is far too low for most of these commenters, I think.
There's a 1 in 10 chance your doctor has seriously thought about killing himself because of the stress of his job. Yes, this is above everyone else in any high-risk field except the military.
Yet somehow, somewhere, the American public has become convinced the doctors are all greedy bastards who work 40 hour weeks and drive around in fancy cars. Somehow, it is the doctor's fault. NPs and PAs are honest, good, true professionals. Doctors are just in it for the cash and prestige. Doctors don't care. Doctors are in the pocket of big pharma.
Why go through that sort of hatred if you don't have to? A 2-4% suicide rate is far too low for most of these commenters, I think.
11
The AMA is losing a grip on their monopoly because many studies are already saying 10-14 years to become a physician in the USA is overkill. Being able to train 4-14 Nurses for the cost of one doctor is a pretty clear indictment of the system, particularly, when Registered Nurses are in the frontline diagnosing and caring for many patients.
2
Americans rely too much on doctors, who more or less hold them up for ransom at the slightest whim. In what other profession (discounting politics) can you make more that $500.00 per hour without batting an eyelash? I got charged $192.00 for an office visit at which the MD had nothing to say because the results of the tests he ordered had not reached him, and another $192.00 for the five minute visit I had with him when he finally did have the results. Total time with MD: 8-10 minutes. That means he could have four or five times as many patients in an hour. You calculate. I find I can do quite well via the internet and only see an MD when I am very sick.
2
For the past year I've been seeing a nurse practitioner as my primary care provider. It is never difficult to get an appointment, waiting room time is not excessive, and she is much more responsive and accessible than any of the internists or family practice MDs I saw over the past few years. I don't live in a rural area and there are plenty of MDs nearby, including my previous very unsatisfactory internist, but this nurse practitioner is far and away the best caregiver.
11
These days, when you go to see your PCP, they listen to your complaint, and if it's beyond a minor cold, cough or sprain, you inevitably hear "I am going to have to refer you to a specialist." Right. A Nurse Practitioner can say exactly the same thing for less money. I am all for it!
6
Perhaps others have mentioned this thought, but it seems these areas for screaming to finance some doctors' educations and have them come to work off their loans over a certain number of years...
Couldn't counties find a way to finance two or three younger doctors or is it just such a depressing area that none want to work there?
Couldn't counties find a way to finance two or three younger doctors or is it just such a depressing area that none want to work there?
4
As a Nebraska-raised woman, I'm biased. But I would think someone interested in outdoors medicine would want to come here. And, of course, practice the other stuff.
Hooray for nurse-practitioners.....and all primary care providers, including doctors. Over and over again, NPs have demonstrated their skills and judgement. A good NP knows when to seek additional help for a patient. Doctors should grow up and treat NPs as colleagues. Only the weak are threatened by positive change.
4
Such changes in how medicine is practiced are a mixed bag, at best. Somebody with some training of some sort is better than nobody with any training of any sort. In remote areas, this can be good. But, there are some medical specialties which complex enough that they can't be be practiced by nurse practitioners. At that point, a referral to a specialist is the order of the day.
Although, these laws may slightly lower the costs of getting treated for maladies, they also lower the bar needed to treat illnesses. Plus, markets tend to adjust to such changes. Once a nurse practitioner realizes she is the only one in 500 miles doing medicine, she may raise her rates.
2
As a physician assistant who trains NP students, let me just say there is a vast difference in the way NPs are trained compared to the training of PA and MD students. NP students are trained on the nursing model, whereas PA and MD students learn from the medical model. They take "nursing theory" classes and no one yet has been able to tell me how this helps them care for patients. In short, they don't have the same critical thinking skills because of their training, not because of lack of aptitude. NPs are only required to do 16 hours of clinical rotations per week. That's not even part time. And they only have one year of clinical rotations. This is done of course so that they can keep working as nurses while going to school, but I don't know of any MDs or PAs who could keep their job and go to school. So, based on this amount of training, NPs should be able to practice medicine independently?
And of course only MDs and DOs in hospitals/clinics should be called doctor. Getting a DNP degree and being called doctor suggests that they are doctors. Everyone intuitively knows they are not. I work with PharmDs and I don't call them doctor nor do they expect to be called doctor.
And of course only MDs and DOs in hospitals/clinics should be called doctor. Getting a DNP degree and being called doctor suggests that they are doctors. Everyone intuitively knows they are not. I work with PharmDs and I don't call them doctor nor do they expect to be called doctor.
15
J Kramer: Speaking as an NP who has worked among PAs, you exhibit all the arrogance and ignorance of some of my less-respected colleagues. Nursing theory is probably the fundamental reason nurses are so trusted and well-liked by patients. Examples of nurse theorists include Florence Nightingale, who noted that the environment (fresh air, fresh water, light, effective sanitation and cleanliness) aid a person's recovery from illness; and Hildegard Peplau, who stated that nursing is a therapeutic, interpersonal process and recognized the give-and-take partnership between nurse and patient (as opposed to the prevailing idea that patients passively receive treatment). Any good health care provider today, whether s/he is an MD/NP/RN/PA, practices these theories every minute. The fact that RNs work during NP school is really an additional part of their education; it is a residency of sorts, synthesizing what is learned in NP school while on the job as an RN. The weekly clinical hours in NP school is *in addition to* 40+ hours weekly of working as a nurse. Not everyone who is a DNP insists on being called doctor; besides, PhD's, PsyD's, and anyone with a doctoral degree can be called doctor. It sounds like you have a personal grudge against NPs. PAs were created by physicians specifically to function under the thumb of the physician. Perhaps your anger is better directed to the AMA who will refuse to recognize your competency for what it is, or has the potential of being.
1
J Kramer: Speaking as an NP who has worked among PAs, you exhibit all the arrogance and ignorance of some of my less-respected colleagues. Nursing theory is probably the fundamental reason nurses are so trusted and well-liked by patients. Examples of nurse theorists include Florence Nightingale, who noted that the environment (fresh air, fresh water, light, effective sanitation and cleanliness) aid a person's recovery from illness; and Hildegard Peplau, who stated that nursing is a therapeutic, interpersonal process and recognized the give-and-take partnership between nurse and patient (as opposed to the prevailing idea that patients passively receive treatment). Any good health care provider today, whether s/he is an MD/NP/RN/PA, practices these theories every minute. The fact that RNs work during NP school is really an additional part of their education; it is a residency of sorts, synthesizing what is learned in NP school while on the job as an RN. The weekly clinical hours in NP school is *in addition to* 40+ hours weekly of working as a nurse. Not everyone who is a DNP insists on being called doctor; besides, PhD's, PsyD's, and anyone with a doctoral degree can be called doctor. It sounds like you have a personal grudge against NPs. PAs were created by physicians specifically to function under the thumb of the physician. Perhaps your anger is better directed to the AMA who will refuse to recognize your competency for what it is, or has the potential of being.
Thank you for writing in. I was just about to post asking for the perspective of a PA, a field I once considered upon retiring from teaching.
WHAT NURSES KNOW I hear stories from an RN friend about who knows the patients better in hospitals, where there are usually plenty of doctors. It's the nurses, because they're on the front line. In fact in some teaching hospitals, the chief resident will let the interns and other residents know to consult with nurses about the care of patients. That's because the nurses work on rotating shifts, and have often learned a lot about how the doctors they work with see the cases. For that reason, the nurses can often recognize presenting symptoms and needs with a new patient better than novice interns or even residents sometimes. So if nursing services are so crucial in a hospital setting where there are plenty of doctors on staff, properly trained nurses can perform at the same level independently. In fact, over the years, who gets more time with senior physicians, nurses or interns and residents? Since internships last 1 year and residencies usually up to 3 years, nurses who have been around 5 years have more face time with doctors than do doctors in training. In fact, it might be a good idea to restructure medical practice, requiring doctors to become nurses before admission to medical school. Working on the front lines gives a different perspective. In a few years, after the primary physicians who are baby boomers retire, there will be no choice. Nurses will have to provide much more care. Unless we raid physicians worldwide who take jobs US doctors don't want.
2
We are already "raiding". Should we forget that physicians are needed in much of the rest of the world even more than in the US?
I prefer to see a nurse practitioner at my doctor's office when I have an issue like the flu or a minor infection. But I learned the hard way that a nurse practitioner is no substitute for a doctor when I had a more serious problem that needed a diagnosis. In that case the NP misdiagnosed me and I did not receive the correct treatment until six months later when I sought a second opinion from another doctor's office where I was able to see an actual doctor. My doctor's office never got me in to see the doctor - just keep funneling me to the NP no matter how many times I asked to see the actual doctor.
13
I am a physician, but also a patient at a prestigious complex medical system. Although I see my physician regularly there, the every day care is relegated to and managed by nurse practitioners. I may be biased, but I am yet to encounter a a nurse practitioner with the competence, (I believe) intelligence and with the sense of responsibility of my physician. I have often had to manage my own care, and worry about patients who do not have the background I do. I think this delegation of care to nurse practitioners is a symptom of our fractured medical system, not a bonus.
In response to what Dr. Reinhardt (health economist) states about the "economics and common sense" of nurse practitioners doing primary care without doctor supervision, the situation of nurse practitioners may well change when they discover that responsibility means liability (they will be sued, not the M.D.). I also wonder how someone like Dr. Reinhardt would feel if diagnosed with a serious illness, and his care is provided by a nurse practitioner.
In response to what Dr. Reinhardt (health economist) states about the "economics and common sense" of nurse practitioners doing primary care without doctor supervision, the situation of nurse practitioners may well change when they discover that responsibility means liability (they will be sued, not the M.D.). I also wonder how someone like Dr. Reinhardt would feel if diagnosed with a serious illness, and his care is provided by a nurse practitioner.
76
Everyone has the right to choose their health care provider. If you are uncomfortable with the "competence, intelligence, and sense of responsibility" of the NPs in your doctor's practice, you have every right to request that your follow up appointments be only with the MD.
1
Pretty amazing comment from RGD. I particularly liked the "I am yet to encounter a nurse practitioner with the competence, intelligence and sense of responsibility...". Sounds like the AMA provides everything we need for good medical care. RGD could probably discover that there is a large range of competence and dedication among physicians and the same is likely to be true for NPs and PAs also. Take time to talk to and quiz your medical practitioner and don't hold them up as deities.
2
I previously lived in a small community served by a nurse practioner whose judgements were not overseen by a physician. Some diagnoses made were later found to be incorrect with serious consequences. Yes, I have also had an exceptionally positive experience with another unsupervised nurse practitioner, but I would not look to that individual for decisions on any but relatively minor concerns. Our medical system is profoundly flawed to the level of the patient being little more than a name in a file and on a check, considered for a few minutes, then back in the cabinet. A follow up phone call to see how the patient is doing? How the inevitable prescription is working? Caution on side effects or other concerns? That's covered by "make another appointment for more of the same on your way out".
I absolutely agree with RGD: "This delegation of care to nurse practitioners is a symptom of our fractured medical system, not a bonus." It's just another appearance of medical care being given when little substance is present. I've helped trusting, unsophisticated family members survive miserably complex, fragmented, inept medical systems that required long, determined, efforts to get through to the skilled persistent doctors and nurses who could and did make a life saving difference for them. This step with unsupervised nurse practitioners is just another dangerous, frustrating, layer of let's pretend we are providing something we are not - quality medical care.
I absolutely agree with RGD: "This delegation of care to nurse practitioners is a symptom of our fractured medical system, not a bonus." It's just another appearance of medical care being given when little substance is present. I've helped trusting, unsophisticated family members survive miserably complex, fragmented, inept medical systems that required long, determined, efforts to get through to the skilled persistent doctors and nurses who could and did make a life saving difference for them. This step with unsupervised nurse practitioners is just another dangerous, frustrating, layer of let's pretend we are providing something we are not - quality medical care.
3
One drawback my family recently discovered is that, under Medicare rules, a NP cannot write hospice or home health care orders. We had to switch our elderly mother to a different provider at a very vulnerable time because her NP was practicing independently (some are affiliated with MD's). It's a silly rule; at the point where the pt is going to hospice, an MD gets less important and making the pt comfortable in his/her last months is well within the NP's practice.
4
The Internet provides the perfect medium for 'virtual' medical teams. Sorry Doc's, this may relegate you folks to less 'God-like' status, but you've got to admit that the era of 'Earth God's' has long since passed, not to mention the fact that we can't find enough candidates, educate enough candidates, or afford the inefficiencies of our current system of tree-structure based, hierarchical medical control.
We need more readily expandable, far reaching, accurate, and consistent health care delivery systems. Perhaps, not quite on the order of manufacturing, but as close as possible.
We have the information and the technology to begin a transition to 'Star Trek-Age medicine. Now we need to muster the will to bust the cartel and ease health care out the comfort of its 7000 year old mystical roots.
What if, in addition to psychiatric help, there were robotic diagnostic, and operating machines in these remote locations? How many lives would be saved, how many more services would be available, and how much money would be saved through a reduction in the education and training required to deliver effective medicine?
We need more readily expandable, far reaching, accurate, and consistent health care delivery systems. Perhaps, not quite on the order of manufacturing, but as close as possible.
We have the information and the technology to begin a transition to 'Star Trek-Age medicine. Now we need to muster the will to bust the cartel and ease health care out the comfort of its 7000 year old mystical roots.
What if, in addition to psychiatric help, there were robotic diagnostic, and operating machines in these remote locations? How many lives would be saved, how many more services would be available, and how much money would be saved through a reduction in the education and training required to deliver effective medicine?
I would not want a robot to make or treat a psychiatric diagnosis.
1
Unfortunately, patient care is not a video game. There is no "perfect medium" for learning patient care other than the actual care of patients in an office, hospital, or on the battlefield. These on line degrees in 'advanced training" in patient care are, by definition, fraudulent.
i have a phd in a technical field and am a full time researcher. it is taking many years of continuous academic-type learning to develop specialized knowledge for research because researchers work at the edge or boundaries of what is known, where methodological innovations take place. many areas of clinical practice (such as primary care), by contrast, confine themselves to applying what is known. while it often also takes years of hard work to master the known, that work typically occurs in a clinical, rather than academic, setting, where formal academic training is less important than improved judgment formed by the experience of treating patients. I suspect such is why many patients express a higher degree of satisfaction with NPs than internal medicine physicians. Experiential-based treatment innovations in diagnosing ultimately trump knowledge of root biological causes.
5
As a practicing NP for 20 years, I've heard these pros and cons go back and forth ad nauseum. My patients are lucky to have me as I am a damn good, knowledgeble practitioner. I consult with the physicians in our practice a few times a month, and I know when I need to, or when I need to refer to a specialst....just like all good primary care providers. (Most of them are amazing doctors A few I wouldnt refer to my worst enemy.) There's good and bad in all professions. That being said, I believe 95% of graduating NPs are woefully inadequate to practice under their own licenses. I graduated from a top named university and I thought their program was spotty, incomplete, very deficient in clinical training. MS degree level training does not guarantee clinical competence, or teach good judgement. It takes far far more on the job training as an NP than an MD to be a competent provider. That said, NPs have a vital role to fill in tomorrows health care concerns and addressing today's problem of access, and we should be able to crack open the self serving physician monopoly. If NPs want to practice on their own, they should at least be required to complete further (one year +?) residency after graduation and a specific board certification exam that limits them to their practice in their chosen field. (by the way, NPs and PAs are much more tightly regulated and disciplined under their respective state governing boards. MDs are much more loosely regulated and monitored).
10
One year of residency? Are you kidding??? That's exactly why I choose the MD with his 4 years of residency than the NP who has no residency or just a year!
Nurses, particularly Nurse Practitioners, are often the backbone of health care. It's past time to give them the respect and authority they deserve.
4
It was always my understanding that the AMA ( the doctors Union for all intents and purposes) worked to keep the number of physicians in this country arbitrarily low. Supply, demand = greater remuneration. I'm not sure if this is true, but if it is the physicians in this country are simply reaping what they have sown. I can think of no other country in the westernized world where the number of physicians/ population is so meager.
11
No, the bottleneck is the funding for graduate medical education following medical school, done in academic medical centers, the VA, an teaching hospitals. After medical school, a physician completes a residency (such as internal medicine, family practice, or pediatrics for primary care physicians), and may then do a fellowship to further specialize. Right now, there are more medical school slots than there are residency slots, which is insane - a percentage of graduating medical students have no expectation of finding a residency program when they graduate, and if they don't get a residency after graduation, it's even harder to get one a year later when competing against all the new med school grads. The AMA lobbies for more funding on various levels to open new residency spots, and in no way tries to restrict the number of physicians.
6
It's absolutely not true but since it doesn't fit in with your (or America's) narrative of greedy doctors policing their borders, you won't believe me.
Residency slots are controlled by the federal government, not the AMA. We have been lobbying for years to have the number increased but given Congressional gridlock and underfinancing of Medicare, it isn't happening. So you end up with MDs and DOs who are't trained completely and can't get board certified. Congress. Not AMA.
There is a shortage of med schools but the AMA can't magic them out of thin air. Hospitals need to give students a place to train during third and fourth year. Increasingly, hospitals are unwilling to do so.
Residency slots are controlled by the federal government, not the AMA. We have been lobbying for years to have the number increased but given Congressional gridlock and underfinancing of Medicare, it isn't happening. So you end up with MDs and DOs who are't trained completely and can't get board certified. Congress. Not AMA.
There is a shortage of med schools but the AMA can't magic them out of thin air. Hospitals need to give students a place to train during third and fourth year. Increasingly, hospitals are unwilling to do so.
5
No it is funding from Medicare for residency programs that keeps the numbers down. Speak with you elected officials instead of blaming the AMA, which only represents 17% of US doctors, anyway.
1
I keep reading these comments from nurse practitioners about how they train medical students and give them advice. Okay.
Once these students graduate from medical school, do a residency program, a fellowship, and become board certified, do they still come to you nurses for advice? Do they call you in on a consultation?
How many oncologists call in a nurse practitioner for advice and guidance when they examine a patient with cancer?
Nurse practitioners have they role in the medical field but they are not medical doctors even if they have a doctorate degree in nursing. At the end of the day, regardless of their advanced degrees, they are still nurses.
The sooner the legislatures in this country stop this foolishness, the better off medical care will be.
Once these students graduate from medical school, do a residency program, a fellowship, and become board certified, do they still come to you nurses for advice? Do they call you in on a consultation?
How many oncologists call in a nurse practitioner for advice and guidance when they examine a patient with cancer?
Nurse practitioners have they role in the medical field but they are not medical doctors even if they have a doctorate degree in nursing. At the end of the day, regardless of their advanced degrees, they are still nurses.
The sooner the legislatures in this country stop this foolishness, the better off medical care will be.
24
"how many oncologists call in a NP for advice..." I worked in oncology for 16 years as an NP and I was called in often! for advice on side effect symptom management, social issues, comfort and end-of-life. You had better hope that when you are ill you have a TEAM of providers working with you. We each have our expertise and skillsets and the BEST healthcare is that that is provided when the patient needs it.
No healthcare provider works in a vacuum and the provider that does--with a complex disease like cancer--is the kind of foolishness you should run from.
No healthcare provider works in a vacuum and the provider that does--with a complex disease like cancer--is the kind of foolishness you should run from.
63
When I practiced as a NP specialist in infertility (trained by fellows in reproductive medicine) I had OB/Gyns consulting with me so yes, depending on the training/experience of the NP, physicians DO consult with us. By the way, as a hospice nurse, my MD also consulted with me, our chaplain, and social worker, on the plan of care for a patient. Please stop thinking that "medical expertise" is the be all, end all, of healthcare--it's only a piece of it. Depending on the patient's immediate health needs, any number of healthcare professionals will be called in for consult.
7
Thank you for this. When I am a patient, I want to work with providers who are willing to consult with others who have the relevant expertise to help me get the care I need. If that means my MD consults with an NP--yes, please. And vice versa. If any of my providers feel a need to compete based on professional boundaries (or hubris), let them do it on their own time, and please leave me out of it.
3
For me, it comes down to quality of care. About 3 years ago,I went to the clinic and was told that I would be seeing the doctor. She came into the room and asked me what was going on. She examined me and said I had a certain medical issue. I was alarmed and discouraged. She called in one of her fellow doctor to also have a look at it. He took one look and said my condition was not what she said it was and it was rather benign.
She was a nurse practitioner with a doctorate in nursing, so the staff called her doctor (which was technically correct due to her educational level). On the other hand, he had graduated from medical school. This is not a case of sexism because if the sexes were reversed, the outcome would have been the same.
I was taught that a doctor was someone who graduated from medical school. If these nurses want to do what a doctor does, they should attend medical school and do a residency.
As a patient, I would rather see a "real" doctor instead of someone called "doctor" because they have a doctorate degree in nursing.
There really is a difference in their education and body of knowledge. And I even discussed the malpractice issue.
She was a nurse practitioner with a doctorate in nursing, so the staff called her doctor (which was technically correct due to her educational level). On the other hand, he had graduated from medical school. This is not a case of sexism because if the sexes were reversed, the outcome would have been the same.
I was taught that a doctor was someone who graduated from medical school. If these nurses want to do what a doctor does, they should attend medical school and do a residency.
As a patient, I would rather see a "real" doctor instead of someone called "doctor" because they have a doctorate degree in nursing.
There really is a difference in their education and body of knowledge. And I even discussed the malpractice issue.
26
One thing you can do is ask, "Are you a physician?" Several states are taking steps so that people with advanced degrees such as physicians, nurses, chiropractors, dentists, etc have to disclose their credentials rather than simply and ambiguously be referred to as "doctor."
The fact is that surgeons are essentially micro-plumbers, and robots can either do the job or highly assist folks who may have long forgotten year 7 of their 11 year medical education.
Diagnostics? Medical knowledge is escalating at a geometric rate, and most doctors are already relying on the 'net' for diagnostic, and pharmaceutical guidance. As we develop a comprehensive database of case histories, medicine will advance at an even more greater pace (remember humans are capable of processing about 30 pieces of information a minute.........self driving cars process 100 a second).
The computers are simply faster, increasingly more accurate, emotionally more stable, mentally less biased, and absolutely more durable and resilient than their human equivalents. The information databases are infinitely more comprehensive and capable than any doctor's memory, and Artificial Intelligence, aided by the repetitive nature and speeds of computers is progressively eating into the world of creativity (that is the correlation of seemingly unrelated information and patterns along with the ability to simulate cause and effect related to possible alternatives).
Will there be 'horror stories' and mistakes? Absolutely, the change may suffer some initial consequences of human frailties, however, the infinite persistence, consistency, and availability of information will slowly fill any gaps in the knowledge and practice of providers. People die from mistakes now!
Diagnostics? Medical knowledge is escalating at a geometric rate, and most doctors are already relying on the 'net' for diagnostic, and pharmaceutical guidance. As we develop a comprehensive database of case histories, medicine will advance at an even more greater pace (remember humans are capable of processing about 30 pieces of information a minute.........self driving cars process 100 a second).
The computers are simply faster, increasingly more accurate, emotionally more stable, mentally less biased, and absolutely more durable and resilient than their human equivalents. The information databases are infinitely more comprehensive and capable than any doctor's memory, and Artificial Intelligence, aided by the repetitive nature and speeds of computers is progressively eating into the world of creativity (that is the correlation of seemingly unrelated information and patterns along with the ability to simulate cause and effect related to possible alternatives).
Will there be 'horror stories' and mistakes? Absolutely, the change may suffer some initial consequences of human frailties, however, the infinite persistence, consistency, and availability of information will slowly fill any gaps in the knowledge and practice of providers. People die from mistakes now!
Your story simply does not ring true. I have never heard of any physician calling in a nurse practitioner (not matter what "advanced degrees" she has) to make a diagnosis. A doctor calls in another physician and puts that in the chart. If this scenario were to come up in a possible malpractice case, the insurance company would settle in record time.
I'm sure that teaching hospitals could send residents and fellows on rotation through these underserved areas as part of their training.
5
By world standards, our medical system is the equivalent of a car with 3 flat tires. Sending it on long rides through the countryside isn't going to solve any problems.
1
They still need supervision by physicians during training.
It really should be required. We in the prairie states need the spectrum of clinicians, nurse, PA, doctor, nursing assistants.
1
Agree that a psychiatric nurse should be able to set up a practice to see and talk with patients, like a psycholigist would (? what is the difference in their training). But don't agree that they should prescribe medicine. There are a number of reactions that patients can have, and interpreting that is complex. What about having the local pharmacist sign off - someone that can see what other meds that patient is on. Or require the nurse to document that they've talked with the pharmacist?
We have many doctors in this country, shortages today occur in geograpically remote locations. But with the ACA, too much disruption has occured and insurance companies have been given too much power, as has HHS, over our care. This is a problem and part of the reason that some are reconsidering becoming a physician, and the reason some are leaving medicine.
We have to have exceptions in our laws (e.g. mid-wife delivers baby vs. OBGYN). However, prescribing meds is tricky business. When someone has a psychotic episode and kills a bunch of people as a result of being on the wrong dose of a med - who is responsible? Today, it's the doctor and they pay BIG bucks to be insured and spend a lot of time on continuing education to assure they understand and are held responsible when negligence occurs.
Wonder why Murlene didn't look into this before her education; wonder why she wasn't taught this by the university she attended? Where did she get this graduate degree?
We have many doctors in this country, shortages today occur in geograpically remote locations. But with the ACA, too much disruption has occured and insurance companies have been given too much power, as has HHS, over our care. This is a problem and part of the reason that some are reconsidering becoming a physician, and the reason some are leaving medicine.
We have to have exceptions in our laws (e.g. mid-wife delivers baby vs. OBGYN). However, prescribing meds is tricky business. When someone has a psychotic episode and kills a bunch of people as a result of being on the wrong dose of a med - who is responsible? Today, it's the doctor and they pay BIG bucks to be insured and spend a lot of time on continuing education to assure they understand and are held responsible when negligence occurs.
Wonder why Murlene didn't look into this before her education; wonder why she wasn't taught this by the university she attended? Where did she get this graduate degree?
4
Part of the problem with our current approach to pharmaceuticals is that it has become a 'solution looking for a profitable problem'. Cures and beneficial medical outcomes are secondary pursuits.
The significantly key issues associated with pharma solutions is:
1) Side effects (many impossible to pre-diagnose), and incompatible combinations.
2) Trial and error: many pharmaceuticals have been discovered by trial and error, and no one really knows exactly how they work.
3) Once one gets past one or two daily prescriptions, all bets are off as to whether the next symptom is controllable and/or whether it may be worsened by the introduction of another pill.
We need to get back to a process that pursues more 'cure oriented' and specifically targeted solutions that are well understood. We can still use the outlier meds that work under the 'but we don't know exactly why option', but the current $10 dollar a day pill habit is costing society a mint!
The significantly key issues associated with pharma solutions is:
1) Side effects (many impossible to pre-diagnose), and incompatible combinations.
2) Trial and error: many pharmaceuticals have been discovered by trial and error, and no one really knows exactly how they work.
3) Once one gets past one or two daily prescriptions, all bets are off as to whether the next symptom is controllable and/or whether it may be worsened by the introduction of another pill.
We need to get back to a process that pursues more 'cure oriented' and specifically targeted solutions that are well understood. We can still use the outlier meds that work under the 'but we don't know exactly why option', but the current $10 dollar a day pill habit is costing society a mint!
It is to their shame that physician groups continue to fight this. It truly is about ego and money. Nurse practitioners really do not compete with physicians because in almost all cases they provide care to the underserved and refer complex cases to physicians. It seems that they think it should be a physician or nothing at all, and we know who is at the losing end of that equation.
12
The decision to provide primary care is a reflection of the economic opportunities locally available. Nurse practitioners, in rural areas, do what the local economy needs: primary care. Here in South Florida, nurse practitioners open Botox clinics, filling the unmet need of the wrinkled masses who otherwise would go without treatment...
6
Actually, it is about the liability that falls to the physician who is trying to fix what a mid-level did or did not do correctly. It's not about competition - physicians would have no objection if funding were made available to train more physicians, so it's not about having fewer patients to see. If there were a way to shortcut medical training without compromising the quality of the care provided, physicians would be all for it, and would reaffirm their support every month when they write their loan repayment check. But there isn't.
3
Here in my upscale, MD infested neighborhood, I prefer my two favorite NPs to their bosses. Their practices are cardio and dermatology. I find them infinitely more compassionate and caring.
16
Compassion happens when 'opportunistic money' is harder to come by.
When done outside an operating room, inserting a "breathing tube" in, or intubating a patient, is an emergency procedure. The need for intubation is most often due to airway swelling, which progresses in real time. It takes practice on scores--if not hundreds--of patients for a resident physician to learn to intubate. This is ALWAYS with an experienced attending physician coaching, and taking over if need be, which in the initial stages of learning is more often than not. Intubating someone with remote video assistance is just lunacy.
13
You are incorrect in your statement at least twice. I am a nurse anesthetist in a large trauma center in a big city and I teach ER residents to intubate. The ER residency program at this hospital is considered one of the best in the country. I am not the only nurse anesthetist teaching physicians to intubate either so your use of the word always is not based on actual practice. In addition the need for intubation outside of an operating room is not usually due to airway swelling at all. There are many reasons for intubation ranging from a code in which there is no breathing, to increased work of breathing, to an inability to protect ones airway, to swelling of the airway and other reasons as well. Please be sure that you have the actual knowledge and facts on a topic before posting such an extreme comment.
6
Cool, so the person should just die? Do you understand that there are *no* doctors in the region where this nurse is practicing?
6
Yeah, what lunacy. Much better if she hadn't bothered to try and the patient died.
4
So much for telemedicine-but then who wants to pick up the liabilty when things go wrong because the information provide was not complete?
6
The key to that problem is to cut back on 'trigger-finger-law-suits'.
It's good thing that we didn't have lawyers when the wheel was invented or we'd still all be trying to carry the load on our backs.
.......And I guess that the wheel was not particularly favored by the mules, the oxen, the horse, or the 'stone-age-capitalist-uber-by-backpack-providers', but I'm glad we made that step forward.
It's good thing that we didn't have lawyers when the wheel was invented or we'd still all be trying to carry the load on our backs.
.......And I guess that the wheel was not particularly favored by the mules, the oxen, the horse, or the 'stone-age-capitalist-uber-by-backpack-providers', but I'm glad we made that step forward.
We are shamefully under utilizing nurses in this country. I would much rather go to a nurse that actually seems to have the time to talk to me, explore options, and offer alternatives compared to a MD who will generously give me 15 minutes of their divided attention. It seems every nurse practitioner I have seem I have liked more than the doctor they work under. I think the reason for that is nurses seem to learn compassion first and value people over wealth which ultimately makes them morally wealthier
68
The different emphasis in training is true, but what you've experienced is more of a systems problem. I guarantee you would find your experience reversed if the physician were paid on a straight salary and the nurse practitioners were to be paid on production (i.e., your pay gets cut if you don't see the number of patients per hour that the administration expects you to).
1
Like some other commenters, I think this is all fine if you hold NPs to the same standards of responsibility and certification as MDs. One of the reasons that an NP has more time to listen may be that they are in a subordinate position to an MD within their clinical organization. The MD carries responsibility for whatever the NP does, along with whatever else the doctor is responsible for. Doctors are trained much more intensively than nurses, and also held to much higher standards of responsibility and liability. Nurse practitioners vary greatly in quality, since the bar for admission to nursing school is much lower, schooling is comparatively minimal, and the training that happens occurs on the job and so is more limited to whatever specialty they have worked around. I can see the marketplace rationale for empowering NPs, but I can't really see the point of continuing to train doctors if nurses are considered equally qualified. I also know who I would want to see if I or my loved one was really sick...
I can see how it seems this way, but you are mistaken.
The same differences can be seen between medical students and residents. Medical students have a very small workload compared to residents and as a result can spend a lot of time with patients, listen, explain things, etc. Once you take on the workload of a resident or attending physician, all of this changes.
To keep many primary practices financially afloat 15 mins is often too much time. NP's are often not held to the same time constraints, it isn't in their scope of practice. Most doctors would love nothing more than to sit down, listen, and then treat as they see fit. Unfortunately, the system, costs, and reimbursements no longer allow this. Before making negative judgements, try to understand first.
The same differences can be seen between medical students and residents. Medical students have a very small workload compared to residents and as a result can spend a lot of time with patients, listen, explain things, etc. Once you take on the workload of a resident or attending physician, all of this changes.
To keep many primary practices financially afloat 15 mins is often too much time. NP's are often not held to the same time constraints, it isn't in their scope of practice. Most doctors would love nothing more than to sit down, listen, and then treat as they see fit. Unfortunately, the system, costs, and reimbursements no longer allow this. Before making negative judgements, try to understand first.
1
The problem with NPs is that they don't know what they don't. Actually that is really the hard part of medicine. You didn't know that you had colon cancer, but your provider recommended that you get screened, and the unknowable was revealed. So many times, I see NPs on anything more complex than a cold go astray because they do not have the academic background or years or training that MDs have to diagnose anything complex. They give antibiotics for congestive heart failure, or treat aneurysms in the heart as though they are hypertension since they don't know to get an ultrasound. Etc.
24
What irony, the AMA is attempting to stop nurses from providing basic primary care because it affects physician income, but nursing organizations are guilty of the same unethical practice. In some states, nursing associations have successfully blocked community health workers from proving non-clinical preventive health education and promotion because they fill it would threatened their livelihood. Both groups are protecting their profit margins.
5
The fear is not that NP are not trained to treat certain illnesses. As someone within the medical field the treatment for the majority of the illnesses seen in a primary care setting are fairly routine and non-invasive. The issue is in the diagnosis. An MD has 2 years of 40 hours a week training in an apprentice style training with physicians. Following this is at least 3 years of 80 hours a week training in residency. Countless patients are seen. This process is crucial in learning to treat illness, but more importantly to recognize illness. Diagnostic medicine is pattern recognition. You have to see thousands of normal chest X-Rays. That way the abnormal one sticks out like a giant red flag. For every common complaint that a patient sees a primary care physician for there is at least one cause that is life threatening. The ability to differentiate between the common cold and a "don't miss diagnosis" only comes after years of training under the supervision of practicing physicians. A physician seeming cold and distant is of course off putting, but I would rather them know within two seconds of walking in my patient room that nothing is wrong with me (because they have seen my exact presentation thousands of times before) than have to talk with me for 15 minutes to try to figure it out. And unfortunately in the current system of education NP do not have the widespread mandated clinical on site training that MD's do.
27
I think you nailed the flaw with this "NPs listen and doctors don't" argument.
2
I must agree with Beau. I am a psychiatrist and work with 5 psychiatric nurse practitioners and 1 PA. I admire and respect their hard work and commitment to patient care. The young practioners are enthusiastic and eager to learn. The great difficulty they all seem to have is diagnosis. We work with very seriously ill patients and it's difficult to make progress under any circumstances. I often feel they are over their heads, and that's even with supervision. However without their help our system would be overwhelmed. Recruiting psychiatrists is impossible. There are no simple answers.
1
In rural areas, there is a need for rethinking how medical professionals are paid for 'seeing' patients. In parts of British Columbia, far from major cities, the health care system has been testing internet appointments with specialists based hundreds of miles away, with a local nurse being the on-the-ground medical person. This has been a great help for patients who need regular checkups with specialist but who live in areas that would require air flights and overnight stays to see the specialist in person. The nurses take the pulse and blood pressure, follow the doctor's instructions on what to look for, and listen as the doctor talks directly to the patient via internet/video hookup. One of the limits to doing this in the past has been that specialists weren't paid unless they physically saw the patient. I believe the same problems exist in the US where insurance perhaps won't pay for internet appointments.
3
I have a chronic illness that is managed by a specialist (MD) who employs an NP.
Recently, the results of some routine blood tests came back extremely abnormal. I was referred to the NP to discuss the results, who dismissed my concerns and chalked it up to a diagnosis that was in no way consistent with the test results. I had no way of reaching the MD directly because the NP serves as the gatekeeper and only refers patients up the chain "when necessary."
Why did I know the NP was wrong? I'm an MD student. In order to receive the follow up attention I needed, I had to bring my own copy of the test results to the office of another doctor, one who would review the results himself because he does not employ mid level providers.
NPs are certainly capable of providing the care they're capable of providing. But I've encountered far too many that didn't know enough to know what they did not know.
Recently, the results of some routine blood tests came back extremely abnormal. I was referred to the NP to discuss the results, who dismissed my concerns and chalked it up to a diagnosis that was in no way consistent with the test results. I had no way of reaching the MD directly because the NP serves as the gatekeeper and only refers patients up the chain "when necessary."
Why did I know the NP was wrong? I'm an MD student. In order to receive the follow up attention I needed, I had to bring my own copy of the test results to the office of another doctor, one who would review the results himself because he does not employ mid level providers.
NPs are certainly capable of providing the care they're capable of providing. But I've encountered far too many that didn't know enough to know what they did not know.
47
but the question becomes, what happens when an MD is not around? Mediocre NP or no medical care?
2
"Far too many" being one? Anecdotes like yours and the others recounted here don't amount to much. Although I know dozens of people who have had similar experiences with MDs and specialists being dismissive of their symptoms or health problems, that doesn't mean I think they're all poorly trained or clueless. Let's look instead to large scale studies with large sample sizes and significant results. These demonstrate that health outcomes are as good, if not better, when a patient sees an NP. Your story sounds like more of a problem with your specialist's practice than anything else.
1
A better Internet option would help. And it would aid the Republican resistance to changes in the medical system by providing consumers with better information. A transparent health care system would almost meet the requirements of a "market" (of course, there are also those Republicans who believe fair is fair, and who will demand their 'free market right' to exploit the ignorance or misinformation driving the never-ending-gob-stopper, profitable 'suckers that are born each and everyday').
As a current NP student, I was thrilled to read this informative and very well-written article. Nurses are not being used to the full extent of their scope of practice and certainly not to the full extent of their clinical abilities. With so much talk about the "healthcare shortage", it's hard not to become frustrated when I read poor excuses from physicians as to why we should not be allowed the role of autonomous provider. At the bedside, we are often called upon to make snap clinical decisions - especially the night shift - when physicians are difficult to reach, and may not call back at all. I aspire to open my own multi-specialty clinic in a rural area, specializing in primary care and psychiatric care (for children and adults), with an emphasis on telehealth. The emerging field of telehealth is eliminating barriers to prompt, high-quality care for patients (availability, proximity, cost, stigma, etc.) and opening all kinds of doors for providers - it effectively allows for providers to meet patients where they are at via platforms similar to those already widely used (e.g. Skype, etc.). NPs are not trying to and never will "replace" physicians. Our education and approach to the provision of care is much different - nurses assess and care for the patient and family as a whole (spiritual, physical, emotional, etc.) whereas physicians merely treat pathophysiologic symptoms. The desire, skill set, and passion are present in NPs across the country - why make patients wait?
11
Well, good luck. We hope you are required to pass all the medical licensing tests that med students take (parts one and two), serve 3-7 years of residency, and become board certified in your chosen fields, carry the same level of insurance, before you join the ranks of physicians who have traditionally and continue to be on call 24/7 with physician back up, see nursing home patients, make house calls, take roster call at the local hospital for uninsured patients. At least you won't have a hundred grand or more of educational debt to worry about like those kids coming out of med school.
9
Why must she pass medical school tests when she didn't go to medical schools?
NPs normally work full time as bedside nurses before going on to graduate school. You feel that time does not equate to a residency? Why?
You feel that NPs need to experience the hazing quality of physicians being on call for 24 hours? Why?
The two groups have different skill sets that overlap quite well. Give NPs credit for what they know!
NPs normally work full time as bedside nurses before going on to graduate school. You feel that time does not equate to a residency? Why?
You feel that NPs need to experience the hazing quality of physicians being on call for 24 hours? Why?
The two groups have different skill sets that overlap quite well. Give NPs credit for what they know!
15
Winchestereast, physicians and nurse practitioners have different titles for a very obvious reason - if you know what you are talking about, that is... We serve different purposes and fulfill different roles in the healthcare field. As stated in the original post, "NPs are not trying to and never will "replace" physicians". You (and many others posting/commenting) seem to be confused. I encourage you to do more research. Try Googling nurse-run clinics and prepare to be put in your place.
And for the record, my father is a very successful pediatrician who has been practicing for over 35 years. He now is in self-owned private practice, along with two NPs, who see patients, prescribe medications, etc. just like he does. NP collaboration with physicians and/or NPs autonomously can work, and does work, every day.
And for the record, my father is a very successful pediatrician who has been practicing for over 35 years. He now is in self-owned private practice, along with two NPs, who see patients, prescribe medications, etc. just like he does. NP collaboration with physicians and/or NPs autonomously can work, and does work, every day.
6
We can train 100 vet techs for what it would cost to train one veterinarian, but I wouldn't call a tech if my dog were sick. Hospitals like to hire nurse practitioners because they order expensive on-site tests covered by insurers, refer to hospital-employed specialists, and can be cheaper to hire & insure than fully qualified board-certified physicians. In many small towns, hospital and government subsidized groups of np's, in new government subsidized buildings, are the nail in the coffin for non-subsidized individual primary care physicians running their own practices. Does anyone wonder why we have a shortage of well-trained physicians in primary care? Many NP groups are more expensive over-all when you consider the lead NP (as in our county) may pull down close to $200K working as an administrator, the others are generating costly referrals for everything beyond the scope of their training...... whether it's coming from your pocket directly, state, federal funding, it's still costing your community.
10
Unfortunately there isn't enough money for physicians to go to these rural communities. To the contrary, hospitals hire nurse practitioners to cover the evening and night time hours which they can't get physicians to do. The comments of winchestereast are not based on facts but fiction. NPs order no more or no less than physicians in the inpatient hospital setting and in the outpatient setting order less. One small comment, the next time you're in the hospital and you have a problem call "Doctor" instead of nurse and see how far it gets you.
The US is dumbing down in all respects, so why not less educated people treating you?
18
If, God forbid, you ever go into cardiac arrest, I (and my fellow RNs & APRNs) will wait until the "more educated" physician to give you CPR. I hope you have all your affairs in order - it may be awhile. After all, what do we NPs, mere peasants in the healthcare arena, know, right?
Thanks for playing. Better luck next time! Good day, sir.
Thanks for playing. Better luck next time! Good day, sir.
@ Robyn T - At the end of the day, I would rather see a doctor than you or your fellow nurses. The level of training that a APRN receives is nothing close to medical school and is not nearly as intense.
Sure, you may be able to help me in an emergency but I still want to see the doctor.
As far as giving CPR, a trained monkey can give CPR.
If you want to do more, there is always medical school
Sure, you may be able to help me in an emergency but I still want to see the doctor.
As far as giving CPR, a trained monkey can give CPR.
If you want to do more, there is always medical school
9
Primary care physicians these days are really just concierge doctors. The rate of referral to other physicians is higher than necessary. The unnecessary testing has become epidemic. So basically the argument against PA's is a bunch of nonsense. Anyone who has had the misfortune to be hospitalized knows who does the actual caregiving. The doctor floats in for a moment or two, glances at a chart, and leaves the work for the nurse. I think gender, money and the gigantic egos of many doctors play a huge role in their argument.
I'll take a NP or PA almost anytime I can.
I'll take a NP or PA almost anytime I can.
23
Yes, the doctor won't deliver your hourly medication, help you to a bed pan, or put lotion of your boo boo. But she/he's the one getting the call Q 2 hours during the night with the result of your blood gases or blood sugar , PT/ INR, or whatever else you've got going on, adjusting the medication, and not getting paid for the service. All in a night's work.
12
I've long thought that doctors need better PR and to be taught this skillset so much better. What do you think the work of taking care of patients in the hospital is? Bringing you medicine or taking your blood? That's a part of it, but it's managing what medicine you get, interpreting results, and making decisions for next steps.
2
Wait a second... doctors _aren't_ ordering too many tests??
9
The medical schools cause the shortages on purpose!
All of the people who make the rules are doctors and they don't want any competition because competition lowers prices.
They do insidious, dishonest things to make sure that as few people as possible become doctors, things like making a rule that only 5 people in a class will pass and the rest fail. It does not matter if 10 people all made an A+, they are still only going to pass 5. The professors will tell you the first day of class how many A's, B's and C's there will be in the class so it does not really matter what the student's real grade is.
Call it job security for greedy doctors but misery for everyone else.
I would rather have an American doctor who got C's than I would have any of the thousands of diploma mill 'doctors' that greedy hospital management companies ship in from 3rd world countries. There were several of them around here that had to leave because no one would go to them, we would just suffer for days until we could get an appointment with a real doctor. They just moved to another town and did the same thing.
It was not bigotry if that is what you are thinking, it was things like my dad dropping a pot of boiling water down his legs and having 3rd degree burns and the doctor giving him a syringe and telling him to go home and pop the blisters! You know that could not have been a real doctor!
All of the people who make the rules are doctors and they don't want any competition because competition lowers prices.
They do insidious, dishonest things to make sure that as few people as possible become doctors, things like making a rule that only 5 people in a class will pass and the rest fail. It does not matter if 10 people all made an A+, they are still only going to pass 5. The professors will tell you the first day of class how many A's, B's and C's there will be in the class so it does not really matter what the student's real grade is.
Call it job security for greedy doctors but misery for everyone else.
I would rather have an American doctor who got C's than I would have any of the thousands of diploma mill 'doctors' that greedy hospital management companies ship in from 3rd world countries. There were several of them around here that had to leave because no one would go to them, we would just suffer for days until we could get an appointment with a real doctor. They just moved to another town and did the same thing.
It was not bigotry if that is what you are thinking, it was things like my dad dropping a pot of boiling water down his legs and having 3rd degree burns and the doctor giving him a syringe and telling him to go home and pop the blisters! You know that could not have been a real doctor!
4
What an idiotic statement. If these kids, who scored 800's on their math SAT's, were interested in making millions, they'd be hedge fund managers.
7
winchestereast,
very, very few people from even the top business schools go on to become hedge fund managers. Having a medical degree, on the other hand (even with the investment of $300,00 [a top business school goes for about the same thing if you include opportunity cost of employment lost]), still guarantees high salary, ownership of own business, the ability to sell that business, limited competition (licenses to practice medicine - not in hedge fund management) all make it lucrative. ANd this applies to just about all doctors. In business only a few top make anything matching an MDs salary. Hence an MD is a far better bet if you understand that median salary of a doctor is far higher than median salary of top MBA (and the word "top" needs to be emphasized).
very, very few people from even the top business schools go on to become hedge fund managers. Having a medical degree, on the other hand (even with the investment of $300,00 [a top business school goes for about the same thing if you include opportunity cost of employment lost]), still guarantees high salary, ownership of own business, the ability to sell that business, limited competition (licenses to practice medicine - not in hedge fund management) all make it lucrative. ANd this applies to just about all doctors. In business only a few top make anything matching an MDs salary. Hence an MD is a far better bet if you understand that median salary of a doctor is far higher than median salary of top MBA (and the word "top" needs to be emphasized).
If a kid can make it through college and med school and residency then they deserve it. It's tough and requires really intelligent, sharp minds.
Some of my physicians employ nurse practitioners or physician assistants on their staff. I noticed that the PAs/NPs are the ones who work the late hours, weekends and some holidays presumably because the MDs don't want these hours. In any case, when I call for an appointment, I specifically ask if the NP/PA is available because I find them not only to be more compassionate and interested but they don't rush the visit. They are willing to take the time to explain and answer questions. Rather than the physician's highfalutin ideas about PAs/NAs not having adequate training to care for patients, they are more afraid that these professionals will take over their territory.
21
George, MD's are usually on call 24/7 with coverage by other MD's when they're not. Someone with an MD is quarterbacking the PA/NP, schlepping to the hospital to see that ICU admit at 3 AM, and logging onto a computer at home at 5 AM to go over labs, change heparin/coumadin doses, coordinate with the visiting nurses for hospice admits on holidays, getting the call from the police in another state who've found the MD's card in the wallet of a confused patient lost on the pike, making the house call at 8 PM for an elderly house bound patient in trouble.
14
Physicians need to get over the idea that nurses are competitors and find ways to work together. Nurse practitioners, sadly, are no more likely to go to underserved areas than doctors are - that is why they are underserved in the first place. Few medical students are choosing generalist careers despite the demand, the same is true for nurses and physician assistants. The problems of communities with no or little care will persist, despite physicians, NP's or PA's until society and medical education get it right.
12
If legislators want "nurse-doctors" they should pass legislation that codifies the medical boards of quality assurance between nurse practitioners and medical doctors. That would protect patients from medical malpractice. Nurse practitioners who are given wide scope of practice authority should have the same responsibilities as physicians.
6
You mean pass the certifying boards, carry the same level of malpractice? Not a bad idea.
5
the question is what happens when MDs are not in that part of the country? NP or no medical service? Which is preferable to someone in the middle of no where (or where MDs refuse to reside)?
The barriers to entry for NPs is pretty low. A few years ago I went to see an FP for an infection and the NP sent me to the pharmacy with a scriot for something I am vastly allergic to, despite my telling her of the allergy. Thank goodness the pharmacist caught it. Needless to say, I won't use an NP anymore. You should not either!
10
And the government wants affordable quality.
1
Because if you have an "MD" at the end of your name, you're automatically immune from prescribing drugs the patient's allergic to. Am I following?
Seriously- a quick Google search reveals that MDs prescribing meds their patients are allergic to happens all the time. It's unfortunate this happened to you and thankfully the pharmacist caught it, but you shouldn't be using your anecdotal experience with one health care provider to stand for an entire profession.
Seriously- a quick Google search reveals that MDs prescribing meds their patients are allergic to happens all the time. It's unfortunate this happened to you and thankfully the pharmacist caught it, but you shouldn't be using your anecdotal experience with one health care provider to stand for an entire profession.
10
I love my GP, but still I have to occasionally remind him that I have one kidney, which influences what he'll prescribe.
3
Using well trained Nurse Practitioners is a good idea so long as they're limited to the field of their training. Physician/Specialist help can be enlisted via Internet connection if necessary using high definition video where sight is needed. The Nurse Practitioner can set the patient up for basic care while inputting vital statistics for a doctor to analyze. Simple testing of blood and urine can produce them as needed. A back up for transportation to a fully equipped hospital is a necessity. In the case of a suspected heart attack the Nurse can prep the patient and stabilize him while a helicopter can be sent to bring the person in. If teh Doctors won't move to these isolated areas then some compromise must be made to allow basic procedures until an evaluation says more and better experience is needed elsewhere.
3
T from New Orleans: Just re-read your comment after posting my response, and realized that you were talking about 4th year medical students, not 4th year residents. All I can say is, - are you kidding me?!?! Part of my role as an NP at a major teaching hospital in NYC was to teach 4th year medical students when they rotated through my department. Your contention that these smart, earnest, but entirely clueless (for the most part) STUDENTS have more knowledge and experience than their teacher is truly laughable.
18
If they've been educated well, and have done the usual clinical rotations over their 4 years in Med School, those 4th yr med students will know what they don't know and welcome your experience.... and will continue to train with MD attendings in a variety of departments. You won't know more than they will for long. Their extensive cramming of 'drugs and bugs' has already prepared them at the basic science level - Med School is boot camp.
4
Please elaborate on what your department is and what you are teaching the fourth year medical students. I have been in medicine for over forty years. I have found third year students to be hesitant and inexperienced when beginning their clerkships but rarely "clueless" as you present. And by the time they finished the clerkship, they usually progressed quite a distance. Fourth year med students, for the most part, are not clueless at all. These people are, by nature, quite bright and inquisitive. They can be lazy and detached in their duties but this is a temporary fault when they are under the gun of the house officers and staff. An accurate analogy would be military pilots started out in a Cessna but within two years, flying F 15'. I find your remarks to be both mean spirited and inaccurate. Could there be a deep seated resentment of doctors in general involved here?
Long overdue. More people are waking up to this tremendous
need. Dentistry, the same. Some Northeastern states now
allow, under the supervision of a dentist, assistants to
perform injections, fill and extract. They have added courses in
their technical schools for these particular skills. With the
internet available, as this article states, there is no reason
these nurse practitioners cannot be directed by physicians
online to perform more tasks. Good Luck to them.
need. Dentistry, the same. Some Northeastern states now
allow, under the supervision of a dentist, assistants to
perform injections, fill and extract. They have added courses in
their technical schools for these particular skills. With the
internet available, as this article states, there is no reason
these nurse practitioners cannot be directed by physicians
online to perform more tasks. Good Luck to them.
3
The AMA's opposition is self-serving even though it is in the guise of protecting patients. Further, their argument is not a sound one if you think about it.
APRNs will engage MDs, DOs, or other healthcare professionals when necessary just as MDs engage specialists. This way the cost of more specialized care would be incurred only when it is warranted. Certainly, a primary care physician (PCP) does not need to be supervised by a neurologist for treatment of neurologically related problems that the PCP feels capable of handling. Even though a neurologist has had more education than the primary care doctor about such problems. When the neurologist is needed the PCP makes a referral and depending on clinical issues, patient and primary care provider, and reimbursement plans this specialist will become part of the patient’s healthcare team and at times play a leadership role.
I’ve been an RN for over 25 years and have a pretty good sense of what is involved in the education of APRNs, their safety record, and scope of practice among the various specialties. I would not hesitate to have an APRN as my primary care provider or to have one caring for myself, mother, or son.
APRNs will engage MDs, DOs, or other healthcare professionals when necessary just as MDs engage specialists. This way the cost of more specialized care would be incurred only when it is warranted. Certainly, a primary care physician (PCP) does not need to be supervised by a neurologist for treatment of neurologically related problems that the PCP feels capable of handling. Even though a neurologist has had more education than the primary care doctor about such problems. When the neurologist is needed the PCP makes a referral and depending on clinical issues, patient and primary care provider, and reimbursement plans this specialist will become part of the patient’s healthcare team and at times play a leadership role.
I’ve been an RN for over 25 years and have a pretty good sense of what is involved in the education of APRNs, their safety record, and scope of practice among the various specialties. I would not hesitate to have an APRN as my primary care provider or to have one caring for myself, mother, or son.
17
things most Medical Doctors don't want to do:
"My objective is to help build the collaborative work cultures needed for safe, cost-effective care and healthy career paths. Areas of expertise: Whole systems' work, group dynamics, teambuilding, organizational culture, emotional intelligence, complex adaptive systems, interprofessional communication, and transformative leadership."
This may be satisfying work for Beth, but most physicians simply want to practice withing the scope of their speciality
"My objective is to help build the collaborative work cultures needed for safe, cost-effective care and healthy career paths. Areas of expertise: Whole systems' work, group dynamics, teambuilding, organizational culture, emotional intelligence, complex adaptive systems, interprofessional communication, and transformative leadership."
This may be satisfying work for Beth, but most physicians simply want to practice withing the scope of their speciality
1
I wonder how people would react if their school district decided to fire all teachers and hire college grads. After all, a college student can do everything that a teacher can. Right?
somehow doctors have become money grubbing evil know -nothings, while nurses have become the solution to all problems.
the main push for NPs come from the bean counters. Fire doctors and hire NPs which will bring more profits! Publish lots of articles about how much better they are compared to those uncaring doctors.
My office just hired a NP. Her pediatric experience? Nothing. And yet she will be seeing your kids.
The NPs in those pharmacy and retail based "clinics" also have NO pediatric focused training.
Every pediatrician has 4 years of med school and 3 years of residency. In residency they seemail ONLY children. A nurse practitioner can start seeing kids without any child specific training.
what do you think the MD was doing during those 3 years of extra training? You think that training has no worth?
I am fine with NPs working without doctors if they can pass a board exam specific for the area they wish to practice. If they can do it? Fine. If not? MD supervision. If NPs really are just as good, they will have no objection to passing the same tests I have to pass.
somehow doctors have become money grubbing evil know -nothings, while nurses have become the solution to all problems.
the main push for NPs come from the bean counters. Fire doctors and hire NPs which will bring more profits! Publish lots of articles about how much better they are compared to those uncaring doctors.
My office just hired a NP. Her pediatric experience? Nothing. And yet she will be seeing your kids.
The NPs in those pharmacy and retail based "clinics" also have NO pediatric focused training.
Every pediatrician has 4 years of med school and 3 years of residency. In residency they seemail ONLY children. A nurse practitioner can start seeing kids without any child specific training.
what do you think the MD was doing during those 3 years of extra training? You think that training has no worth?
I am fine with NPs working without doctors if they can pass a board exam specific for the area they wish to practice. If they can do it? Fine. If not? MD supervision. If NPs really are just as good, they will have no objection to passing the same tests I have to pass.
17
Your analogy holds up--it's called Teach for America, a highly regarded, prestigious program for college grads.
That is not true. The NPs in pharmacies and retail based clinics are generally Family Nurse Practitioners (FNPs), who are NPs that receive primary care education and clinical training for both adults and children. That of course is in addition to the pediatric education received at the undergraduate nursing level.
If your office hired an NP without any pediatric education, clinical rotations, nor clinical experience in pediatrics to care for children...well...that is the fault of your office. They should have hired an FNP, who does receive such education, and not an adult-focused NP, which is the only way your scenario makes sense.
If your office hired an NP without any pediatric education, clinical rotations, nor clinical experience in pediatrics to care for children...well...that is the fault of your office. They should have hired an FNP, who does receive such education, and not an adult-focused NP, which is the only way your scenario makes sense.
Pardon my disgust, original poster, but you clearly have no knowledge whatsoever of the education nurses are required to go through. As a requirement of our Bachelor of Nursing (BSN) programs, we take courses in pediatrics, gerontology, adult (med-surg), psychiatry, and a host of others and are required to spend many, many hours in clinicals with that particular patient population. Upon graduation from nursing school, one is not automatically granted the title of registered nurse (RN). S/he must sit for a 265-question test that covers all of the aforementioned, along with pharmacology, pathophysiology, lab interpretation, etc., to prove beyond a shadow of a doubt they have the knowledge to provide safe, competent care. If you receive a passing score (which is difficult), you receive your license. NP programs used to require master's degrees (MSN) and are now switching to doctor of nursing degrees (DNP). In graduate school, you are required to take all of the aforementioned courses AGAIN, but in greater depth and from the slant of an autonomous provider. And yet AGAIN spend many clinical hours with the specific patients (in my program, 300 clinical hours solely working with the associated population - pediatrics, adults, primary care/families)...I'll let you do the math. Upon graduation, yet AGAIN, one must go through the board/licensing process - but this time, in their field of specialization. Your apparent disdain for us as professionals is unfortunate.
2
Good NPs don't want to "doctor:" While we offer patients many of the skills typically associated with MDs, (including assessment, ordering tests, prescribing therapies), the care is delivered with a preventive-focused, patient-centered, nursing-based, style. It starts with listening to the concerns of the individual and eliciting a thorough bio-psycho-social history. Counseling, education and the offering of treatment options are essential to a a person's ultimate well being. I am confident enough to tell my patients when I don't know something; it would never occur to me to treat beyond my scope of knowledge or education.
Follow-up studies need to be done on those NPs ordering excessive lab & radiological studies. I suspect they are being done by newer grads w/ higher academic degrees lacking clinical experience, rather than by seasoned providers. My practice relies on clinical acumen, follows evidence-based guidelines, and above all, focuses on each individual in my care to help that person prevent illness, stay well and to restore health.
Follow-up studies need to be done on those NPs ordering excessive lab & radiological studies. I suspect they are being done by newer grads w/ higher academic degrees lacking clinical experience, rather than by seasoned providers. My practice relies on clinical acumen, follows evidence-based guidelines, and above all, focuses on each individual in my care to help that person prevent illness, stay well and to restore health.
9
You unintentionally highlighted the exact problem with NPs. Attending MDs are "seasoned providers" because they are required to complete an internship and residency after graduating from their degree program.
I wouldn't be surprised if those same metrics were to find that new MD grads (ie interns) had some of the same problems as NPs -- the difference is that MD interns are overseen by residents and attending physicians, whereas NPs are all too often working alone.
I wouldn't be surprised if those same metrics were to find that new MD grads (ie interns) had some of the same problems as NPs -- the difference is that MD interns are overseen by residents and attending physicians, whereas NPs are all too often working alone.
3
Instead of arguing about nurses vs doctors, we should address how health-care practitioners in rural areas can be connected to the expertise of leading research centers. In my rural area we have doctors, but everyone knows that if you have more than a cold you should get in a car and drive to the nearest major medical center or you'll end up with sub-standard care. Rural practitioners don't see the range of exotic problems that major medical centers do, nor have the time to keep up with the latest research. How can we use the power of the modern communications to solve this problem?
10
Amen.
I feel I may have the right to comment here: I'm a doctor. When I was a medical student, I went to an NP for all my health care...loved her. Now I work with many NP/PAs in an under served area. I couldn't do a third of what I do without them. They allow me to take care of many more patients than I would otherwise be able to do because of all of the paperwork and administrative duties that have been foisted upon me by the government. But that's another rant for another day. Can they work independently of me? yes MOST can.
However, it is with the teamwork that we have that we are able to take care of some of the most in-need patients. We are a surgical service but end up doing a significant amount of primary care as well because of a severe shortage of primary care physicians in the area.
We have to find a way to make access to care, good care for all, a priority. The current system is near breaking. The medical schools are sending me more and more med students that are poorly prepared for the realities of residency, the government has limited the number of md residents I can train. There will soon be US medical school grads who won't be able to train because there are not enough residency spots. The number of docs won't be increasing so someone will need to fill the voids. For most of is on the front lines, we just want to make sure that we are doing the best for our patients.
I feel I may have the right to comment here: I'm a doctor. When I was a medical student, I went to an NP for all my health care...loved her. Now I work with many NP/PAs in an under served area. I couldn't do a third of what I do without them. They allow me to take care of many more patients than I would otherwise be able to do because of all of the paperwork and administrative duties that have been foisted upon me by the government. But that's another rant for another day. Can they work independently of me? yes MOST can.
However, it is with the teamwork that we have that we are able to take care of some of the most in-need patients. We are a surgical service but end up doing a significant amount of primary care as well because of a severe shortage of primary care physicians in the area.
We have to find a way to make access to care, good care for all, a priority. The current system is near breaking. The medical schools are sending me more and more med students that are poorly prepared for the realities of residency, the government has limited the number of md residents I can train. There will soon be US medical school grads who won't be able to train because there are not enough residency spots. The number of docs won't be increasing so someone will need to fill the voids. For most of is on the front lines, we just want to make sure that we are doing the best for our patients.
101
I understand your statement. In large part, you are right. However, surgery? I had an unfortunate experience in Butte Cty, CA with an NP who decided to remove a small growth on my leg - she wanted to test for malignancy. All she needed to do was to scrape enough to put on a glass plate. Instead, she gouged out a large piece of my inner leg. The test was benign. The gouge took some time to heal with a special salve and left a scar. Supposedly, she was under the supervision of an MD. The MD never even entered the room. A different outcome occurred in Stamford, Ct with a similar small growth examined by an MD who scraped a small sample, tested it, found it benign and gave me a salve to treat it. No cuts, no scar. The NP was unskilled and unsupervised. I still live in the same place, and have discovered a wonderful Walk-in with two doctors and two nurses. If they think something might be serious, they refer to a different medical group. As when I fractured my shoulder; an x-ray found it, and I was referred to an orthopedic doctor. I am now ready for physical therapy. No surgery, and no NP's fiddling around with a fractured shoulder.
“The doctors are fighting a losing battle,” said Uwe E. Reinhardt, a health economist at Princeton University. “The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”
I agree nurse practioners will win this in the long run because of economics. If America is to provide care for everyone, it must become cheaper. That means more advanced practioners or punishing pay cuts for physicians. Common sense, however, is not on their side. As a physician in my mid-fifties, I realized that experience allows me to deliver better care. AP's armed with a third of my education working 40 hours per week do not have the same level of experience.
I agree nurse practioners will win this in the long run because of economics. If America is to provide care for everyone, it must become cheaper. That means more advanced practioners or punishing pay cuts for physicians. Common sense, however, is not on their side. As a physician in my mid-fifties, I realized that experience allows me to deliver better care. AP's armed with a third of my education working 40 hours per week do not have the same level of experience.
12
Look at the budgets or the non-profit 501C3/990 filings of some of the NP/AP run clinics - you'll find they are very costly. Administration is top-heavy covered by big government subsidies, high cost for very low-level illness/treatment.... we've looked. They do not come close to small primary care offices in terms of efficiency, but with the high level of subsidy, they don't have to. For-profit 'Doc in a Box' clinics run by mega-retailers treat non-emergent/urgent low risk illness vs primary care private practices with long term cardiac, diabetic, copd, renal failure patients.
1
While NPs may not have as much training as doctors, I have found that the care I received from them was better than a doctor, because the NP took more time to speak with me. The doctor was just in-and-out, as fast as possible, and very impersonal.
Whatever additional training that doctor may have had, never had time to come into action. So what good was it to me? Also, at the time I could see the NP right away, whereas seeing the doctor would have taken 6 weeks. How does a 6-week delay translate to better care?
Some patients don't mind treating their bodies like a car, where you take it to the mechanic and leave it there while the experts tinker. Other people, myself among them, want to be treated as a person, not a machine. I feel that NPs are far better at doing this than doctors, possibly because of their training, or possibly because NP field attracts people with different goals and attitudes.
Whatever additional training that doctor may have had, never had time to come into action. So what good was it to me? Also, at the time I could see the NP right away, whereas seeing the doctor would have taken 6 weeks. How does a 6-week delay translate to better care?
Some patients don't mind treating their bodies like a car, where you take it to the mechanic and leave it there while the experts tinker. Other people, myself among them, want to be treated as a person, not a machine. I feel that NPs are far better at doing this than doctors, possibly because of their training, or possibly because NP field attracts people with different goals and attitudes.
18
First of all Red Ree, it does no good for someone to listen to you when what you're saying is not going through a head filled with education, training and experience related to what you're saying. It is easy to listen when you don't know what the words you're hearing mean in terms of what is going on medically and what might be done to address the problem(s). But what this article really shows - without realizing it - is how the corporations, with the cooperation and collusion of government, have taken control of medicine and are hollowing it out by skimping on the human capital needed for good medical care. Physicians would be glad to work in these "underserved" areas if it was economically viable to do so. But the price-fixing in medicine makes it not viable. Obamacare makes matters much worse, BTW, because - and this is never talked about by the media - because it favors the corporate practice of medicine where even the physicians are employees working in shifts, depending on electronic medical records to know who you are as a person, which is also folly and would be recognized as folly by anyone who took a moment to think about it.
6
The motivation for RNs to become NPs is radically different from many MDs. NPs have goals, but not to join the country club, drive the latest European car or live in exclusive gated communities. The NPs I have worked with or know are driven more toward advanced education to be used in helping people. Many NPs could go to med school and become MDs if they so choose as they are smart, sharp and have everything they need to choose that alternative. However, they choose to become NPs to listen, care and assist their patients to a healthier life. I have the greatest respect for NPs and for what they do in the medical community.
5
This is an unconscionable slam against physicians, who go to medical school to learn how to REALLY help people. Anyone who wants to "join the country club, drive the latest European car or live in exclusive gated communities" should NOT go to medical school and rack up debt but, rather, to law or business school to go to work running hospitals, pharmaceutical and medical device corporations, suing doctors for millions, or in companies that employ doctors or charge them for electronic medical records, recertification, or how not to get put out of business by government audits. Physicians are a dying breed because they "cost too much" to make (hence outsourcing medical education by importing 25-35% of the nation's doctors) and to use, esp when the government-corporate overlords are basically the rancher/farmers and the public are the barnyard animals that have to be looked after. NP's are also taught to do as they're told and follow the rules whereas those "uppity" doctors tend to have their own ideas about what is best for their patients, ideas tey got in those expensive medical schools.
4
Do people know that a NP can work in one field one day, and then a completely different field the next?
How would you feel if you went to get a pelvic exam and later found out the MD was an orthopedic surgeon with alnost no training in female care? Or if you had cancer and found out your MD was an ophthalmologist?
You see, it's not just about being "a doctor"
It's about having the training specific to your field.
An MD must do 3-7 years of training specific to their field AFTER med school. (Called residency). Many have 2-4 years after that (called fellowship )
Then we must be boarded in their field. And we can ONLY work in that field
An NP has none of that
An NP is similar to a graduating med student, without fellowship or residency.
They then can and do go to any field.
My office just hired an NP from an Orthopedic clinic. She has NO pediatric experience. None. Think about that. Ortho clinic to Pediatrics.
Yet she started seeing kids last month against our protests.
it happened in part because we are surrounded by those clinics inside of Target and Walmart who hire untrained NPs to see kids.
All about profits. why hire board specialized MDs when you can hire cheaper NPS
keep thinking it's only about jealous doctors trying to keep their cabal.
It's time for NPS to create a new category of specialty training and board certifying. But that would cost money, eliminating their purpose of doctor breaking cost cutters
How would you feel if you went to get a pelvic exam and later found out the MD was an orthopedic surgeon with alnost no training in female care? Or if you had cancer and found out your MD was an ophthalmologist?
You see, it's not just about being "a doctor"
It's about having the training specific to your field.
An MD must do 3-7 years of training specific to their field AFTER med school. (Called residency). Many have 2-4 years after that (called fellowship )
Then we must be boarded in their field. And we can ONLY work in that field
An NP has none of that
An NP is similar to a graduating med student, without fellowship or residency.
They then can and do go to any field.
My office just hired an NP from an Orthopedic clinic. She has NO pediatric experience. None. Think about that. Ortho clinic to Pediatrics.
Yet she started seeing kids last month against our protests.
it happened in part because we are surrounded by those clinics inside of Target and Walmart who hire untrained NPs to see kids.
All about profits. why hire board specialized MDs when you can hire cheaper NPS
keep thinking it's only about jealous doctors trying to keep their cabal.
It's time for NPS to create a new category of specialty training and board certifying. But that would cost money, eliminating their purpose of doctor breaking cost cutters
24
I don't think that is entirely True. Np have specialities:family, pediatric, neonatal, women's health, psych, gerontology, etc. An FNP might see people of all ages but the others have Specific area
6
Hey, that's no different from doctors. Maybe doctors _should_ have specialty training, but they don't have to. How many doctors in fields with money, e.g., plastic surgery, hair transplants, etc., have specialty training or board certification in their field?
4
I hope no one considers you an expert on the subject as you are way in left field on this. As a nurse midwife, I trained family practice residents in obstetrics. I am the equivalent of an OB doctor who has completed his second year of residency. Our one-on-one training is exceptional. Many medical students came to us when we were still students to check on certain procedures because they read it and then were expected to do it.
5
Nurses are not doctors, everyone is aware of it but either non availability or refusal of doctors to work in towns and remote areas must have resulted in this sort of precarious situation.
There should be some sort of binding on the medical graduates to work in rural areas at least for five years so that everyone will have the access of doctors in the field of internal and family medicine, dentistry, vision and psychiatry to start with.
The medical association should try its best to solve the problems rather than opposing any legislation in favour of practicing nurses.
In the event of shortage of doctors, medical seats can be proportionately increased to meet the shortage.
There should be some sort of binding on the medical graduates to work in rural areas at least for five years so that everyone will have the access of doctors in the field of internal and family medicine, dentistry, vision and psychiatry to start with.
The medical association should try its best to solve the problems rather than opposing any legislation in favour of practicing nurses.
In the event of shortage of doctors, medical seats can be proportionately increased to meet the shortage.
7
When you send med school graduates to rural areas are you going to wipe out their med school debt and pay them a decent wage, cover the cost of opening a practice, supply them with competent staff? Do we require grocers to deliver food to underfed neighborhoods? Bus drivers to make runs in areas where public transportation is lacking?
1
So what are you suggesting? You seem very anti NP and very pro MD, but do you actually have suggestions for providing care in underresourced areas?
wincherereast,
you ask the questions that you do then oppose NPs in these vary areas. Why? You obviously admit that MDs will not practice there. That means that people living there have no access to an MD. A NP would seem the only alternative (as inferior to an MD as that may be). Someone with some medical knowledge or experience, in most cases, is clearly preferable to no medical access at all.
you ask the questions that you do then oppose NPs in these vary areas. Why? You obviously admit that MDs will not practice there. That means that people living there have no access to an MD. A NP would seem the only alternative (as inferior to an MD as that may be). Someone with some medical knowledge or experience, in most cases, is clearly preferable to no medical access at all.
As a consulting cardiologist, I have had the opportunity to work with both referring MD's and mid-levels, both NP's and PA's. As in all fields, not only medicine, there are MD's, and mid-levels who are well trained, conscientious, and know when to appropriately consult. On the other hand, I often get consults from both groups that indicate they are simply attempting to triage patients to the appropriate consultant, with little forethought. There are some, again in both groups, who are the most dangerous, who don't know what they don't know. So it is difficult to generalize. The MD residency training does not seem as rigorous as many years ago, This all changed with the Libby Zion case many years ago. There are some MD's who are coming out of training without the experience of seeing through a tough case overnight. Some of these new physicians are very unsophisticated, and practice defensive, and thus, very expensive medicine. It's a dilemma that hopefully can be improved with true tort reform.
4
Will NPs charge the same ridiculous amounts of money doctors do?
3
There is an important place in the health care system for NP's and PA's. While the system's flaws make their work more important, mid-level providers are valuable because of what they can do, not because of systemic shortcomings. Physicians already employ NP's and PA's to do much of the work that is less risky and complicated. Much of clinical work is routine and does not require the extensive training that physicians obtain, punctuated by the occasional surprise or complication.
As with all medical providers, NP's and PA's must use judgment as to when to refer or consult with others. Independence practice, i.e. without the legal requirement of working in collaboration with a physician, only means that they are being increasingly trusted to know their limits and collaborate with others appropriately - something that all providers, including physicians, sometimes fail to do.
The profession of nurse practitioners has established a good record of training providers properly, and that model has received support through independent review, such as that of the Institute of Medicine. The profession has also aspired to enhance the quality of NP practice by raising the training standards required for practice to a higher-level degree.
So the question is not if NP's can do all the work of MD's, but whether they can now be trusted to independently add value to the American health care responsibly and professionally. That seems to be the case.
As with all medical providers, NP's and PA's must use judgment as to when to refer or consult with others. Independence practice, i.e. without the legal requirement of working in collaboration with a physician, only means that they are being increasingly trusted to know their limits and collaborate with others appropriately - something that all providers, including physicians, sometimes fail to do.
The profession of nurse practitioners has established a good record of training providers properly, and that model has received support through independent review, such as that of the Institute of Medicine. The profession has also aspired to enhance the quality of NP practice by raising the training standards required for practice to a higher-level degree.
So the question is not if NP's can do all the work of MD's, but whether they can now be trusted to independently add value to the American health care responsibly and professionally. That seems to be the case.
I worked temporarily training NP's. Their knowledge is minimal even after certification. Overestimating and publicizing their own capabilities increases risks for the patients. If possible see a trained medical doctor.
1
Maybe they should import some witch doctors ????
1
A few thoughts-
Isn't it interesting that a nurse now in many places can get an NP and immediately begin practicing independently, but a physician must do at least three years of residency and become board certified to gain privileges at almost any hospital, which in turn is required to be a provider for almost any insurer?
One local dermatology practice has 2 doctors and 8 PA/NPs. Those PAs and NPs had no special training in dermatology when they started working there - they were taught on the job. So why does a doctor have to spend 4 years in a derm residency to do the same thing? I'll bet the dermatology board would freak out if a substantial number of doctors began calling themselves dermatologists based on working in a derm practice.
And finally - $500 per month is too much for taking on legal liability and time commitment for supervising a nurse in a field where suicides and subsequent lawsuits happen? It seems to me this nurse is unreasonable. If nurses want to practice independently, I expect their insurance premiums will skyrocket.
Isn't it interesting that a nurse now in many places can get an NP and immediately begin practicing independently, but a physician must do at least three years of residency and become board certified to gain privileges at almost any hospital, which in turn is required to be a provider for almost any insurer?
One local dermatology practice has 2 doctors and 8 PA/NPs. Those PAs and NPs had no special training in dermatology when they started working there - they were taught on the job. So why does a doctor have to spend 4 years in a derm residency to do the same thing? I'll bet the dermatology board would freak out if a substantial number of doctors began calling themselves dermatologists based on working in a derm practice.
And finally - $500 per month is too much for taking on legal liability and time commitment for supervising a nurse in a field where suicides and subsequent lawsuits happen? It seems to me this nurse is unreasonable. If nurses want to practice independently, I expect their insurance premiums will skyrocket.
10
There are advanced practice nurses that already do practice independently in 20 states. Please demonstrate the skyrocketing of their insurance premiums.
Nurse Practitioners are not cheap labor. They have the same cost as MD's when providing care to patients. NP's require advanced training and education to deliver care to patients. Nurse Practitioners are the future of primary care in this country. Correct, there is no short cut to learning how to take care of patients. #KellyCares
Why even bother to have doctors? The US and Canada have only themselves to blame for shortages. I've heard this bellyaching for years. Why are there shortages? I will tell you exactly why: governments do not have the will to take on the doctors, who are content to have a closed, limited network. There is a lack of funds to pay for doctors. Insurers and government really do not care if you wait - or if you die. How do I know this? I was part of a lobby group for International Medical Graduates once. It was a farce. There are enough fully trained, highly skilled doctors on par with any Doc there, who would gladly fill the shortages no matter where there are. How do I know? I am married to one. An Anesthesiologist who chose to stay in his home country because of the indignities and impossibilities he faced in the US and Canada. Now, who needs an Anesthesiologist? I know a great one! Ready, able and willing to go wherever he is needed.
4
Curious....why did the state of Maryland sign a similar law? There is certainly no shortage of doctors. Is this purely to provide a less expensive alternative or is there another reason that may be associated with the legislation?
2
Why are so many questioning the ability of NP's to assess, diagnose and treat? Why question the ability of the psychatric NP to diagnose and treat psychiatric disorders?
Even an NP's knowledge of physiology and pharmacology is being questioned in many of the comments. NP's have been around for 50 years, with the first NP program starting at the University of Colorado in 1965. This is not a new profession.
Numerous studies have found that NP's clinical care of patients is equal or exceeds that of physicians.
Np's have 4 years of education as RN's, and usually have several years of experience as an RN, then an additional 2-4 years in a highly focused master's or clinical doctorate NP program. NP's are educated in internal medicine, family medicine, pediatrics, ob/gyn, psychiatry. NP's do not receive the basic training in surgery as medical students do, and most are not educated in the hospital management of patients.
Np's buy their own liability insurance. NP's are sued, but at low rates. If something goes wrong in patient care and the patient sues, it is the NP who is primarily sued, not the collaborative physician.
In most of the states that continue to require a an NP to have legal relationship with a physician, the legislation defines the relationship as "collaboration,"not supervision.
Even an NP's knowledge of physiology and pharmacology is being questioned in many of the comments. NP's have been around for 50 years, with the first NP program starting at the University of Colorado in 1965. This is not a new profession.
Numerous studies have found that NP's clinical care of patients is equal or exceeds that of physicians.
Np's have 4 years of education as RN's, and usually have several years of experience as an RN, then an additional 2-4 years in a highly focused master's or clinical doctorate NP program. NP's are educated in internal medicine, family medicine, pediatrics, ob/gyn, psychiatry. NP's do not receive the basic training in surgery as medical students do, and most are not educated in the hospital management of patients.
Np's buy their own liability insurance. NP's are sued, but at low rates. If something goes wrong in patient care and the patient sues, it is the NP who is primarily sued, not the collaborative physician.
In most of the states that continue to require a an NP to have legal relationship with a physician, the legislation defines the relationship as "collaboration,"not supervision.
7
I repeatedly hear "numerous studies" show that NP are the equal of FP. Actually, when these bills are put before state senates for consideration, the proponents cite two studies. And one of these "numerous" studies cited the other. This is emblematic of the magical thinking which is being flung about in this most contentious yet highly unproductive discussion.
1
No malls and no Wal-Mart. The HS has 4 students. There are more angus cows roaming around than humans in this desolate area of Nebraska.
A newly licensed psychiatrist is the only resident on a 14 mile road is starting up her practice. She plans to "drive the wheels off" her 2004 Ford Taurus. I think she'll spend 10 times the hours on the road getting to a patient than she'll spend treating them. And she'll probably be able to count the number of patients she treats yearly on both hands.
Then I think about Appalachia where there are tons of poor illiterate people living in trailers with hardly basic infrastructure of electricity, plumbing, food, hygiene and medical which would provide a psychiatrist with work 7 days a week.
A newly licensed psychiatrist is the only resident on a 14 mile road is starting up her practice. She plans to "drive the wheels off" her 2004 Ford Taurus. I think she'll spend 10 times the hours on the road getting to a patient than she'll spend treating them. And she'll probably be able to count the number of patients she treats yearly on both hands.
Then I think about Appalachia where there are tons of poor illiterate people living in trailers with hardly basic infrastructure of electricity, plumbing, food, hygiene and medical which would provide a psychiatrist with work 7 days a week.
4
If NPs and PAs are low cost alternatives, why do their services cost the same to patients as MDs services? Only the clinic/hospital and insurance companies see any cost savings. The patients end up paying full price.
13
Lots of comments about whether NP's are qualified to "practice" but little about how the entire issue of availability of health care professionals in this country is driven by the choice the turn health care into a commodity.
As long as this basic essential human service is simply another product in the marketplace we will be faced with problems like these. While medical schools do offer loan forgiveness incentives for doctors to locate to rural areas it's obviously not enough.
It's amazing that we insure that all regions of the country are serviced by a post office, but not by a doctor. Oh, I forgot. Congress is trying to privatize the mail and screw that up as well.
As long as this basic essential human service is simply another product in the marketplace we will be faced with problems like these. While medical schools do offer loan forgiveness incentives for doctors to locate to rural areas it's obviously not enough.
It's amazing that we insure that all regions of the country are serviced by a post office, but not by a doctor. Oh, I forgot. Congress is trying to privatize the mail and screw that up as well.
11
The use of nurse practitioners in faraway, desolate places is a boon to health care and will raise the standard of living in these places. I was in a suburban oncology practice that utilized nurse practitioners in clinic and accompanied us on hospital rounds, and after a while, we realized that we could not do without them. They were an asset in every way. There are some downside though and it cuts both ways. While true that overworked physicians can't spend enough time with patients and NPs allow them to it has to be recognized that complex cases are not in a NP's bailiwick and management of chronic illnesses like diabetes and hypertension should have physicians set the course with the NP's role being to check the status and make sure the patient remains on course. Ordering of expensive tests is sometimes a reflex action but
is no substitute for knowledge, whether by MDs or NPs. It is important to recognize when one is over one's head and make referrals rather than just order more and more tests. This is true of both MDs and NPs.
That said, NPs have made a huge impact on the health system and their involvement is generally to be welcomed.
is no substitute for knowledge, whether by MDs or NPs. It is important to recognize when one is over one's head and make referrals rather than just order more and more tests. This is true of both MDs and NPs.
That said, NPs have made a huge impact on the health system and their involvement is generally to be welcomed.
5
Nurses are not doctors. Their training differs as do their experiences. Clearly there is a role forth is chronic care management and the diagnosis of minor ailments. Please do not write another article about physicians going into specialties and not primary care. Nurses will own that like the barefoot doctors of China. Probably the biggest beneficiaries will be trial lawyers.
6
The bottom line is that nurse practitioners are cheap labor and the decision makers in this country love cheap labor. In addition, we live in a country where everyone wants to be considered an expert without having the requisite education and training to be considered qualified.
There is no short cut to learning how to take care of patients. Nurse practitioners are not the answer.
There is no short cut to learning how to take care of patients. Nurse practitioners are not the answer.
33
Why does it appear that the majority of the negative comments regarding NPs seem to come from MDs?
Michael, let me get this straight... you would rather wait weeks or months (or longer - does the VA scandal ring a bell?) to see a physician rather than have similar (note: similar does not equate to verbatim), high quality care from a nurse practitioner either the same day or a few days thereafter? There is no logic to be found in your post. The "cheap labor" bit is too nonsensical to address. I encourage you to research the didactic and clinical requirements for RNs and APRNs (NPs, CRNAs, CNMs, etc.) before attempting to state "facts". When you or your loved one finds themselves in a state of less-than-optimal health or wellness, give us NPs a call. We'll be waiting.
1
I would prefer today's NP over a Doctor 50 years ago, anytime.
9
That does notmake sense. You are not getting a Doc from 50 years ago,
1
The Governor of Nebraska should be commended for allowing Nurses to Practice Medicine in the state.
Generally most of the patients come with pretty basic medical problems that can be diagnosed & alleviated at the Nurses level.
Added to which is the fact that in a sparsely populated regions like Nebraska the Nurse to Patient interaction can be psychotherapically beneficial to Patients & off course the Nurses as well.
In the good old days in China this first line medical interventist were known as " Barefoot Doctors"
I expect a steep decline in Mental health issues & a general perk up in Moods.
Keep it up Doctor Nurses!!.Thank you Governor
Generally most of the patients come with pretty basic medical problems that can be diagnosed & alleviated at the Nurses level.
Added to which is the fact that in a sparsely populated regions like Nebraska the Nurse to Patient interaction can be psychotherapically beneficial to Patients & off course the Nurses as well.
In the good old days in China this first line medical interventist were known as " Barefoot Doctors"
I expect a steep decline in Mental health issues & a general perk up in Moods.
Keep it up Doctor Nurses!!.Thank you Governor
13
Having worked with NPs and seen the studies of their care they end providing more costly care - they do not have the depth of training as physicians do (that is why they are cheaper to train). They are quicker to refer to a specialist, quicker to order expensive and unnecessary tests. When studied the optimal ratio of physician to midlevel provider for supervision was 1:1. That has been my experience as well.
They are terrific for extending services but are not ready for prime time.
They are terrific for extending services but are not ready for prime time.
If nurses want to be doctors, then they should go to medical school. I work with NPs and they are very good. But NPs are not trained to do what doctors do, have as deep an understanding of pathophysiology and pharmacology and should not practice without supervision and access to a physician. It works best when NPs are part of a team. We should be doing better for rural areas that cannot recruit physicians. Solo NPs is a less than optimal solution for these communities.
24
And what is the solution in rural areas such as that described in the article? If MDs are unwilling to go where the need is then any care is better than no care. My rural area of Vermont, which is hardly rural at all compared to the Sandhills, has a very, very difficult time recruiting primary care docs to our three-clinic Federally Qualified Health Center--and we're only 20 miles from Dartmouth-Hitchcock Medical Center!
Please, before you state that nurse practitioners are not the solution look to the unwillingness of doctors to do their part.
Please, before you state that nurse practitioners are not the solution look to the unwillingness of doctors to do their part.
1
With technology now, a doctor can be in the house.
No doctor and no NP is the least optimal solution for these communities.
I work with a lot of nurses who do most of their NP courses online and laugh at how they are doing busy work for these courses. The clinicals are also not at all rigorous, and are self-arranged, often at "easy" sites.
Then I see medical students who have a very intense course of study, plus years of residency training.
There is no comparison. The PAS and NPS I work with are heavily supervised and know their limits. But we pay large malpractice premiums to be able to practice and have midlevels there. If they want to take the same risks, they need to pay the same malpractice premiums. The $500 a month this woman won't pay is little next to the $5000 a month of premiums that I pay for a malpractice insurance policy in a field that has a mid level of risk. NPs can get sued at Minute Clinic, too.
Then I see medical students who have a very intense course of study, plus years of residency training.
There is no comparison. The PAS and NPS I work with are heavily supervised and know their limits. But we pay large malpractice premiums to be able to practice and have midlevels there. If they want to take the same risks, they need to pay the same malpractice premiums. The $500 a month this woman won't pay is little next to the $5000 a month of premiums that I pay for a malpractice insurance policy in a field that has a mid level of risk. NPs can get sued at Minute Clinic, too.
23
AMA is a deeply reactionary, self-serving and self-dealing factor in national health care. While one would like to think their objections to nurse practitioners' new responsibilities are because they care for patients, history, close relationships to Big Pharma together with the fierce lobbying against fee transparency argue against the altruistic motive.
10
But in this case, Big Pharma is firmly at odds with the AMA. And there is no fee transparency issue here. There is little or no money to be made out in those isolated areas. Office visits and follow ups with some home calls. Of these, the government pays a pittance. FPs out there can barely keep their lights on. The money that the corporate pirates are after is not out in the sandhills, but in the strip malls of suburban Omaha where they aim to drive every family practice doctor out of the neighborhood and replace him or her with a NP based in a pharmacy or attached clinic with a large share of the fee going directly to them and not to their new tool.
1
Seems to me that many in this discussion are missing the point. In rural communities, the option isn't MD/DO vs NP/PA. It's NP/PA vs no one. I'm now living in rural Alaska, where even midlevel providers are scarce and unlicensed villagers are trained to provide many primary care services. They save lives every single day, making clinical decisions and accessing physicians over telehealth as needed (and when it is working). NPs aren't trying to be MDs; paramedics aren't trying to RNs. But when existing members of a community are able to provide primary physical and mental health care, and triage and stabilize emergencies and crises, we should all be thrilled! (Oh, and as a former hospital RN -- 4th year medical students are rescued every shift by RNs who keep them from harming patients. They don't compare well to experienced NPs or PAs by any metric besides classroom hours and student loan debt).
81
"Just finding someone who can listen. That's what we are missing."
These words are so true! And not just related to therapy in terms of mental health. Even where doctors are plentiful, it is often the Nurse Practitioner, with her nurse's training, who LISTENS.
i have noticed this again and again. And in one particular instance, after my spouse had been complaining for years of pain in his side, but been reassured by different doctors that his pain was simply due to past open heart surgery, the Nurse said, "Why don't we get an X-ray? It's probably muscular, but just in case.." Well, the next morning, she called to have him come back for lung function testing and a CT or maybe it was an MRI. well, it turned out he has a chronic and progressive lung condition!
We never forget that nurse LISTENING!
These words are so true! And not just related to therapy in terms of mental health. Even where doctors are plentiful, it is often the Nurse Practitioner, with her nurse's training, who LISTENS.
i have noticed this again and again. And in one particular instance, after my spouse had been complaining for years of pain in his side, but been reassured by different doctors that his pain was simply due to past open heart surgery, the Nurse said, "Why don't we get an X-ray? It's probably muscular, but just in case.." Well, the next morning, she called to have him come back for lung function testing and a CT or maybe it was an MRI. well, it turned out he has a chronic and progressive lung condition!
We never forget that nurse LISTENING!
16
Maybe my experience is an aberration but a NP I saw was the worst listener of any medical professional I've seen.
3
Moved months ago to an "underserved" area and found I must drive two hours round-trip to meet with a primary care physician. I researched carefully but soon surrendered: no one locally accepts new patients.
An overlooked irony is that in my field of mental health, in which I have began licensed for nearly 20 years and hold a doctoral degree, I find no reciprocity from state to state.
Even though former President Bush signed an executive order in December, 2006 requiring the Department of Veterans Affairs (VA) to hire counselors as well as social workers, psychologists and mental health nurses, it has not happened.
I left the VA because I cannot use my decades of training and experience there. Of course the lack of reciprocity state-to-state means that to license where I now live (to the Feds in most cases a license in one state equals a license in all states), I must undergo supervised experience for two or three years. Remember: I have been licensed for almost 20 years.
I plan to become a case manager. Why? Because I'm locked out of direct service in mental health care due to fiefdoms among state licensing boards, warring factions of providers, recalcitrant agencies which defy executive orders and archaic practice models. Sad.
An overlooked irony is that in my field of mental health, in which I have began licensed for nearly 20 years and hold a doctoral degree, I find no reciprocity from state to state.
Even though former President Bush signed an executive order in December, 2006 requiring the Department of Veterans Affairs (VA) to hire counselors as well as social workers, psychologists and mental health nurses, it has not happened.
I left the VA because I cannot use my decades of training and experience there. Of course the lack of reciprocity state-to-state means that to license where I now live (to the Feds in most cases a license in one state equals a license in all states), I must undergo supervised experience for two or three years. Remember: I have been licensed for almost 20 years.
I plan to become a case manager. Why? Because I'm locked out of direct service in mental health care due to fiefdoms among state licensing boards, warring factions of providers, recalcitrant agencies which defy executive orders and archaic practice models. Sad.
8
No comment on the appropriateness of nurse practitioners but will suggest that the reference to the Supreme Courts opinion in the case regarding the North Carolina dental board makes implications that are not necessarily warranted. The opinion had to do with the perception of a conflict of interest by the board and the nature of the oversight by the State.
2
With primary care in short supply, it makes no sense for physicians to limit the scope of practice for adjunct medical professionals who are qualified and trained to manage primary care. It also makes no sense for these same professionals to attempt to do everything, including nutrition counseling. Nurses rarely received more than one semester of nutrition education; physicians rarely receive any.
Ironically both professional organizations actively limit work that could be most effectively be executed by dietitians, either by lobbying to limit access to reimbursement (ie: medicare reimbursed obesity counseling does not cover dietitians) or opposing legislation re: scope of practice and licensure (as seen in California). The medical challenges facing Americans require all hands on deck. Shame on them both for putting their own territorial interests in front of the needs of their patients.
Ironically both professional organizations actively limit work that could be most effectively be executed by dietitians, either by lobbying to limit access to reimbursement (ie: medicare reimbursed obesity counseling does not cover dietitians) or opposing legislation re: scope of practice and licensure (as seen in California). The medical challenges facing Americans require all hands on deck. Shame on them both for putting their own territorial interests in front of the needs of their patients.
4
Physicians rarely receive any nutritional training?
My medical school education included a complete physiological basis of every essential nutrient and the metabolic processes that demand those nutrients. In addition, we investigated a comprehensive list of disease states that take hold when such nutrients are missing.
Maybe my education was different than other doctors' education.
Probably not.
My medical school education included a complete physiological basis of every essential nutrient and the metabolic processes that demand those nutrients. In addition, we investigated a comprehensive list of disease states that take hold when such nutrients are missing.
Maybe my education was different than other doctors' education.
Probably not.
Understanding disease and the nutrients is not the same as nutrition counseling. Telling someone what to eat or not eat isn't either. Effective counseling takes into consideration food preferences, access and resources, as well as ability to execute the complex behaviors involved in food purchasing, preparation and feeding ourselves. And the more critical factor is helping clients navigate their own ambivalence re: the readiness and willingness to change. Even if you have the knowledge, is it worth your time to do all of this yourself? Why not refer?
Guess where do np & pa go for their health care... Another np ?
2
Yes -- we do! And sometimes a doctor. But the first choice I and my NP acquaintances make is to see an NP if at all possible.
1
We have too many pas and nps in the east & west coast. It might be time to redeploy them to parts of Iowa, Nebraska, wyoming , Kansas,.... It looks like there are too many in mass. This seems to be a workforce redistribution issue. An np is a RN with a masters in nurse practitioner. Let NPs take on the malpractice risk on their own with no physician supervision. Malpractice lawyers ..please take note...this is a new liability lucrative practice area for you...A patient gets what a patient pays for!
10
NPs have had independent practice in many states for many years. Please demonstrate documented examples of this "new liability lucrative practice area" for malpractice lawyers in those states.
NOT ordering unnecessary tests and procedures is the mark of a more experienced provider. My thoughts are that patients will be cared for well but the cost savings may be quickly negated by the overuse of diagnostics.
5
As a nurse practitioner I appreciate this article, but cringe at the title. We don't doctor. We provide health care that patients need. Calling that doctoring only perpetuates the idea that there are doctors, and then everybody else.
12
But you are. You are doctoring. Your other NP cohorts speak of being independent diagnosticians and practitioners. You are diagnosing, assessing and prescribing medications. This is what doctors are trained to do. The big differences here are the facts that doctors receive much more extensive and vastly superior training to do these duties and are subject to oversight by a medical board whereas the nurses do not.
1
These people are seeing patients in offices using the same tools generally employed by a family practice doctor. They perform diagnosis, construct an assessment and then use the prescription of medicines on the basis of this diagnosis/assessment. That is "doctoring" by what most reasonable people would go by. Calling it something else merely calls into further question the reasoning of those proclaiming this brave new world of health care, a utopia of their own design and making (and designation).
I mostly support this BUT at the same time admit that when seeking out a primary care provider while having a complex medical history, I bypassed both NPs and family practice MDs in favor of a recommended MD who had (adult) internal medicine training and good working relationships with a variety of academic MD specialists. Once life gets complicated, I choose those comfortable with medical puzzle-solving and management.
5
The US should take a page out of other countries (like Australia) that are struggling to staff rural areas with doctors and funnel/restrict foreign medical graduates to low density regions.
Every year thousands of well-trained foreign medical graduates apply and get into residency programs in the US. Many of these are already in poor urban or rural areas, but some do end up in highly desired spots that are taken away from American graduates. These spots are paid for solely by American tax payers. Why should foreign graduates be able to take up the choicest spots, with no guarantee that they will stay after training?
We should funnel foreign graduates into more rural areas for training and allow them to stay in the US post-residency if they agree to practice in a rural area for a set number of years, in exchange for residency, a green card and eventual citizenship. Ever wonder why so many fellows, especially in internal medicine are foreign graduates? They keep taking fellowships to stay in the US. Without the visa, they would be sent back to their countries and take all their hard earned, US tax-payer funded training back with them. It's a win-win for both parties. We get to keep our trained doctors, rural regions get staffed with more MDs and foreign graduates get that American citizenship.
Every year thousands of well-trained foreign medical graduates apply and get into residency programs in the US. Many of these are already in poor urban or rural areas, but some do end up in highly desired spots that are taken away from American graduates. These spots are paid for solely by American tax payers. Why should foreign graduates be able to take up the choicest spots, with no guarantee that they will stay after training?
We should funnel foreign graduates into more rural areas for training and allow them to stay in the US post-residency if they agree to practice in a rural area for a set number of years, in exchange for residency, a green card and eventual citizenship. Ever wonder why so many fellows, especially in internal medicine are foreign graduates? They keep taking fellowships to stay in the US. Without the visa, they would be sent back to their countries and take all their hard earned, US tax-payer funded training back with them. It's a win-win for both parties. We get to keep our trained doctors, rural regions get staffed with more MDs and foreign graduates get that American citizenship.
3
A win-win for both parties? You neglect to consider that many of the home countries have already paid dearly for the medical school education of these doctors with the anticipation that these doctors will provide desperately needed medical care for their own countrymen. For the richer countries to lure the doctors of the poorer countries in the midst of their own health care crisis is most unethical.
Of course. Brain drain is terrible. But these foreign medical graduates are coming by the hundreds per year to the US regardless of our policies. Thousands of foreign graduates are rejected each year. Some people spend years of their lives and thousands of dollars to make it to a US residency. Many (most) eventually do stay in the US. Some practice part-time in their own country and most send money back home to their country of origin to support extended family.
I'm glad to read that more states are allowing Nurse Practitioners (NPs) to practice to the full extent of their clinical education and training, as the 2010 Institute of Medicine's report, "The Future of Nursing: Leading Change, Advancing Health" calls for.
I think that some have a caricatured understanding of what NPs mean when they refer to being able to practice "independently". By this, NPs mean that they are able to practice without mandated oversight/supervision from an outside (non-nursing) profession, doing what they have been educated and trained to do. This does not mean that the NP thinks that he/she knows everything and can do everything. NPs, and all health professionals (whether physician, nursing, physical therapist, etc), know that they can collaborate and consult with other professionals who have expertise in areas that they do not to appropriately care for the patient. NP independence does not change that, and NPs in the 20 states that already have fully independent practice rights continue to consult with physician, nursing, and others to care for their patients.
Numerous academic studies demonstrate the high quality care that NPs deliver, showing that NPs have the education and clinical experience to do what they are licensed to do (diagnose, treat, and prescribe in their respective fields). I hope that more more states continue to recognize what many already have, allowing NPs to be the advanced practice providers they are trained to be.
I think that some have a caricatured understanding of what NPs mean when they refer to being able to practice "independently". By this, NPs mean that they are able to practice without mandated oversight/supervision from an outside (non-nursing) profession, doing what they have been educated and trained to do. This does not mean that the NP thinks that he/she knows everything and can do everything. NPs, and all health professionals (whether physician, nursing, physical therapist, etc), know that they can collaborate and consult with other professionals who have expertise in areas that they do not to appropriately care for the patient. NP independence does not change that, and NPs in the 20 states that already have fully independent practice rights continue to consult with physician, nursing, and others to care for their patients.
Numerous academic studies demonstrate the high quality care that NPs deliver, showing that NPs have the education and clinical experience to do what they are licensed to do (diagnose, treat, and prescribe in their respective fields). I hope that more more states continue to recognize what many already have, allowing NPs to be the advanced practice providers they are trained to be.
13
The only academic studies that support this condition have been from studies heavily made up of NPs or nurses. The one outcome study involved selecting one outcome that was favorable and ignoring many others that were not. When you see the same conclusions in JAMA, NEJM, SCIENCE or NATURE or a massive study done by the CDC or funded by the Gates Foundation, then you will have a leg to stand on.
1
You do not need to go to the remotest rural areas to find that nurses know more than doctors. You can also find the very same here, in Boston in our august institutions by the Charles River.
After a few days on the floor, with a sick relative, we soon found that the nurses were far more attuned to what is happening to patients than doctors. Nurses, after all, spend all working hours with their charges. Doctors spend a few minutes, in one, and if lucky, two rows. Unfortunately the nurse, worried about insulting the doctor's sensibilities were unable to speak freely, and walked on eggshells. I can only hope that under Montana skies, and in other remote places, nurses can stand tall and do what they do best, without worrying about an uninformed doctor questioning their choices.
After a few days on the floor, with a sick relative, we soon found that the nurses were far more attuned to what is happening to patients than doctors. Nurses, after all, spend all working hours with their charges. Doctors spend a few minutes, in one, and if lucky, two rows. Unfortunately the nurse, worried about insulting the doctor's sensibilities were unable to speak freely, and walked on eggshells. I can only hope that under Montana skies, and in other remote places, nurses can stand tall and do what they do best, without worrying about an uninformed doctor questioning their choices.
7
I have a cadre of health providers. Two family med doc's, one a personal friend, one with a sports medicine specialty. But my go-to person is an NP. She diagnosed things the doctors all missed and has been correct on every one. She hassles nasty CVS's pharmacy restrictions on my insurance, a process that took hours, when the folks at the doctors office said "no, we don't do that." She is, in a word, incredible and I would be suffering without her (from ICS, IBS, allergies, you name it). Nope, she doesn't do stents, but when my partial knee replacement had an infection in the bone pin site the orthopedist said "no big deal." The NP said "big deal" and put me on meds, thank goodness. It was infected. It was a big deal. She is a class act. Not that my physicians are bad, but with insurance companies requiring you to only have 15 minutes with a doctor spending the actual time you need is a blessing....and with her I can schedule that time. And I am no stranger to medicine, my mother was a doctor and I went to nursing school. I am happy to have both. But for humanized care the NP wins hands down, because she is running her practice her way....and not the way of some impersonal agency.
24
Ok why even bother with a NP or PA just consult Siri or some free app then order your medicine from Amazon on line on sale from China this is more economical
8
What do you call the physician that graduates last in their med. school class? Doctor.
I have seen doctors at urgent care facilities not fit to diagnose an ear infection. I have seen NPs catch things the doctor missed.
We place way too much emphasis on the credential. Providing consumers with more outcome based statistics would matter far more than the MD vs NP debate.
I have seen doctors at urgent care facilities not fit to diagnose an ear infection. I have seen NPs catch things the doctor missed.
We place way too much emphasis on the credential. Providing consumers with more outcome based statistics would matter far more than the MD vs NP debate.
61
The credential represents the amount of training. Of course it matters.
6
Yeah and 50% of our children are below average. What do you propose we do about THAT?
Check your logic here. What do we call a nurse practitioner who graduates at the bottom of her class? Nurse practitioner.
2
Much of the physician shortage, especially in primary, stems from long term government policies. First, the federal and state governments in conjunction with the AMA have restricted medical education both by limiting the number of accredited schools and limiting caption (a per student subsidy paid to medical schools by feds). As a result, there are not nearly enough medical graduates to meet the demand.
Further, the Medicare/Medicaid reimbursement rates for primary care physicians is much lower than for the specialists much lower. But the debts are the same and the residencies as long. Economically, it makes no sense for the medical student to seek a career in primary care.
Further, the Medicare/Medicaid reimbursement rates for primary care physicians is much lower than for the specialists much lower. But the debts are the same and the residencies as long. Economically, it makes no sense for the medical student to seek a career in primary care.
14
I wish it was simply a shortage of physicians, but its not. In reality, physicians, PA's, nurse practitioners, and people in general simply do not move into small towns and stay put. Even with the offer of lucrative salaries and low cost of living, the lifestyle and alienation is the issue. The entire concept behind non-physician medical providers is that often times they are already living and working in that small town as an RN, paramedic etc. That person can then go off to graduate school for 3 years and come back to their hometown where they will likely work until they retire. The same thing occasionally happens with college kids going off to medical school, but it is rare.
I am currently working in a rural town in New Zealand where the country as a whole has enough physicians; however, can not get them to move to this small town. While, I admit that I will also be leaving after my year, the point behind me being here is that non-physician providers can integrate well into the system. Hopefully, when all is said and done, some of the outstanding nurses and paramedics they have in this town, can go off to become PA's and nurse practitioners.
Finally, it should be noted that PA's and ARNP's in the U.S. graduate typically after 6 to 7 years university education. Physicians in New Zealand graduate after 6 to 7 years which proves that you do not have to have the 8 years plus residency as we do in the Unites States to provide effective health care.
I am currently working in a rural town in New Zealand where the country as a whole has enough physicians; however, can not get them to move to this small town. While, I admit that I will also be leaving after my year, the point behind me being here is that non-physician providers can integrate well into the system. Hopefully, when all is said and done, some of the outstanding nurses and paramedics they have in this town, can go off to become PA's and nurse practitioners.
Finally, it should be noted that PA's and ARNP's in the U.S. graduate typically after 6 to 7 years university education. Physicians in New Zealand graduate after 6 to 7 years which proves that you do not have to have the 8 years plus residency as we do in the Unites States to provide effective health care.
3
Actually, that is not quite right. There has been several new medical schools in recent years, some with a focus on primary care. The issue is not enough residency slots for medical school graduates and foreign medical graduates. The AMA does not control medical schools or number of residency positions. The federal government subsidizes training positions and therefore controls the numbers. The government has been resistant to funding more docs and has allocated more funding in recent years for more nurse practitioners and advanced practice nurses.
2
So it takes 6-7 years to train an MD in NZ, and it takes 6-7 years to train a NP/PA in the US, therefore the NP/PA is or could be equal to the NZ MD?
Is that your position?
You are ignoring the 1) the caliber of the student that enters each program and 2) the rigor of the program. You need to realize that, at least here in the US, the people who go the nursing route have more in common with policemen, firemen, and EMTs than people who go the MD route, who group more closely with the highest achievers in society. That's not to say you can't have outliers, but that is what you see on average. You couldn't just take the nursing group, plop them in an MD program, and expect an equal result. My guess is most would flunk out.
Is that your position?
You are ignoring the 1) the caliber of the student that enters each program and 2) the rigor of the program. You need to realize that, at least here in the US, the people who go the nursing route have more in common with policemen, firemen, and EMTs than people who go the MD route, who group more closely with the highest achievers in society. That's not to say you can't have outliers, but that is what you see on average. You couldn't just take the nursing group, plop them in an MD program, and expect an equal result. My guess is most would flunk out.
2
As a nurse of 20 years in acute care, I know some savvy doctors who run their practice with multiple NPs and PAs here in California. The most trusted personnel have hospital privileges and make rounds in the acute care setting. In states with fewer trauma centers and no physicians in underserved communities, SOMEONE has to do the work, and I'm glad nurses are stepping up with advanced degrees to fill in the gaps. There should be no turf war if the physicians don't want to actually be on the turf, but they have a lot of power over legislation on insurance coverage and liability laws. Referrals can be made, and videoconferencing is a good way to bridge communications and allow this to happen with legitimate coverage claims.
27
What areas doctors won't serve must be served by others, or cast loose from one of civilization's key benefits. Shall we abandon whole parts of our country because of lack of economic incentive to a well-connected class of professional workers?
I do believe that nurse practitioners and physician assistants, perhaps with long-distance video oversight by doctors wherever possible, is about all that is possible. Therefore, it should be done.
The problem exists not only in the Great Plains, but in lightly-populated or remote regions of even the most populous states.
I do believe that nurse practitioners and physician assistants, perhaps with long-distance video oversight by doctors wherever possible, is about all that is possible. Therefore, it should be done.
The problem exists not only in the Great Plains, but in lightly-populated or remote regions of even the most populous states.
84
With affordable "on the spot" blood work without a full lab and many other technological advance becoming a reality, your comment is spot on. Australia is a decade ahead of us in servicing remote locations. A little cooperation from the AMA would be appreciated.
Yes, a practical answer, which we have been using here to treat patients in rural areas of California, is telepsychiatry.
p.s. Bob Dobbs, do you get enough slack?
p.s. Bob Dobbs, do you get enough slack?
Nurse practitioners have been lifesavers for me and for my partner. None of the specialists he had seen for years for other ailments ever took the trouble to listen to his heart. Our small-town NP put a stethoscope on him the first time they met, and discovered a life-threatening aneurysm and failing valve. Visits to a cardiologist and surgeon, and soon the hospital for open-heart surgery were the next steps. Seven months later, he is back at his strenuous job.
My own story pales in comparison, but was still life-altering.
Doctors are great, but nurse practitioners are also essential.
My own story pales in comparison, but was still life-altering.
Doctors are great, but nurse practitioners are also essential.
17
And I was misdiagnosed by a NP resulting in long ter adverse health effects. We all can add to this practice of nonsense by anecdote.
5
Price-fixing - a pervasive part of medicine conducted for years by the govt and the medical ins companies - has the predictable result of causing shortages and other market distortions. Whenever it is said "we can't get a doctor to come here" one has to remember the unspoken addendum "for what the govt and inscos are offering to pay." Simple economics.
7
Very true. No where in this article is this basic fact mentioned. It simply states (repeatedly) "there are no doctors here" and "they can't get doctors to come here". Nowhere was it mentioned that doctors would like to go to these areas to help out but they are unable to set up a viable practice due to insurmountable problems in logistics and economics. They can't make a living in such remote places. They are forced to operate out of hub cities that have a enough of a population to support ancillary staff, lab, x ray, etc. as well as a hospitable that can be sustained. I should also like to point out some other inaccuracies in this story:
1. Physicians do not "charge" NPs 500 dollars to receive oversight supervision. That is the going rate for malpractice and other attendant costs for supervising someone who may be hours away from a primary office.
2. The percentage of people living in extremely remote areas of Nebraska without any physician coverage similar to the area described is not 1/3. It is not even 1/10.
3. To bolster their position, the NP camp repeatedly cites two outcome studies which are described as statistically valid. Yet both of these have been subjected to criticism for being incomplete, inaccurate and biased.
4. The article failed to mention that the heaviest support for this "reform" came from Big Pharma and the "health care industry" which are actively installing NPs in pharmacy clinics in Omaha and Lincoln.
1. Physicians do not "charge" NPs 500 dollars to receive oversight supervision. That is the going rate for malpractice and other attendant costs for supervising someone who may be hours away from a primary office.
2. The percentage of people living in extremely remote areas of Nebraska without any physician coverage similar to the area described is not 1/3. It is not even 1/10.
3. To bolster their position, the NP camp repeatedly cites two outcome studies which are described as statistically valid. Yet both of these have been subjected to criticism for being incomplete, inaccurate and biased.
4. The article failed to mention that the heaviest support for this "reform" came from Big Pharma and the "health care industry" which are actively installing NPs in pharmacy clinics in Omaha and Lincoln.
3
I wanted to take the time to clarify a few important facts. Both PAs and NPs are characterized as "mid-level" practitioners. This does not make them interchangeable roles.
PAs are trained in the same medical model as physicians. NPs are trained in a nursing model that has standard protocols that are followed.
PAs graduate with nearly double the clinical hours and classroom hours as NPs.
Upon graduation, PAs have strict guidelines for the first two years which require a MD/DO to be present 20% of the time and ready availability by phone at all times. This fosters continued education and oversight which is modeled after medical residents training. NPs can hang their own shingle. This article states that they have to have a MD sign off on them having a clinic but it is not the same oversight that a PA legally requires.
Many PAs went into their professions to be physician extenders. We can do the acute visits or tasks our MD trains us to do so they can concentrate on their difficult cases or procedures they prefer to do. We are not trying to be independent and replace physicians. I think many NPs feel the same way. There are also NPs that simply do want to practice completely independently and they feel entitled to it. MDs should be defensive about this because they then have the liability and the responsibility to clean up the occasional disaster that comes of it. All research shows that collaborative efforts leads to the best health outcomes for the patients.
PAs are trained in the same medical model as physicians. NPs are trained in a nursing model that has standard protocols that are followed.
PAs graduate with nearly double the clinical hours and classroom hours as NPs.
Upon graduation, PAs have strict guidelines for the first two years which require a MD/DO to be present 20% of the time and ready availability by phone at all times. This fosters continued education and oversight which is modeled after medical residents training. NPs can hang their own shingle. This article states that they have to have a MD sign off on them having a clinic but it is not the same oversight that a PA legally requires.
Many PAs went into their professions to be physician extenders. We can do the acute visits or tasks our MD trains us to do so they can concentrate on their difficult cases or procedures they prefer to do. We are not trying to be independent and replace physicians. I think many NPs feel the same way. There are also NPs that simply do want to practice completely independently and they feel entitled to it. MDs should be defensive about this because they then have the liability and the responsibility to clean up the occasional disaster that comes of it. All research shows that collaborative efforts leads to the best health outcomes for the patients.
36
Best of both worlds. A collaborative effort in underserved areas. However, it would be impossible to have an MD physically on the premises in most cases because they don't want to live in those areas. Let's find a solution to solve this problem.
I believe that in each patient contact, someone needs to determine whether an NP is good enough or whether they need an MD. Each situation is going to be different. I know many chronically ill patients who would probably be fine many times with an NP, but will sometimes have an unusual crisis and need an MD.
In these rural areas, it's a real problem to get any care at all, so an NP is better than nothing, but an MD must be available when necessary and there has to be trust that the NP will know when it is necessary to send the patient to the MD...
In these rural areas, it's a real problem to get any care at all, so an NP is better than nothing, but an MD must be available when necessary and there has to be trust that the NP will know when it is necessary to send the patient to the MD...
19
Clinical competence requires the recognition of being in over your head, seeking consultation or making a referral. This is as crucial a part of expertise as knowing what to do - knowing when you don't know enough. Some NPs are really savvy; some are not. Psychiatric care is especially slippery- it often attracts the naive & well-intentioned. Until there is a catastrophic outcome, some hubris may increase by the least well trained.
29
In the real world, catastrophic outcomes in all medical specialties are often unrealized even by death. The very BEST doctors, nurses, PA's and other healthcare providers know what they do not know and ask for colleagues' help/seek referrals. These folks are not a majority. To the truly clinically informed, all medical care is slippery--that's why it costs us so much and shakes ethical perspectives.
just like some MDs are savvy...and some are not. In 20 yrs working as an RN and NP in major academic centers, my experience is filled far more MDs who are careless and dismissive than NPs.
The title of this article should be "Doctoring, without the training and knowledge of the Doctor". The shortage of the primary care physicians in the remote or even in the urban centers is a challenge. But letting the newly minted NP/PA to practice without any clinical help/resource in form of a supervising physician is a disservice to the patients. Mental illnesses present with lot of ambiguous symptoms and various degrees of presentation. Lot of clinical experience is required in making the right diagnosis and on top of that the medications used to treat have lot of serious side effects as well. I think the state government should help these NP/PAs to get supervising MDs
And for the people who say that NP/PAs are as good as doctors, I have only to say "eyes cannot see what the mind does not know". Primary care is not "the easy" medicine but the most challenging one as not only you have to have a vast knowledge, impeccable skills to do the physical exam, read EKGs, read xrays and interpret the Lab and other data.
If the NP/PAs can be trained at par as doctors let us get rid of the medical schools and start these NP courses instead.
And for the people who say that NP/PAs are as good as doctors, I have only to say "eyes cannot see what the mind does not know". Primary care is not "the easy" medicine but the most challenging one as not only you have to have a vast knowledge, impeccable skills to do the physical exam, read EKGs, read xrays and interpret the Lab and other data.
If the NP/PAs can be trained at par as doctors let us get rid of the medical schools and start these NP courses instead.
50
Anger at MDs may have spawned this.Often NPs provide care within primary care & specialty office practices with much value. It is a big difference to function as an independent practitioner. Very dangerous.
I think you forget that PA/NP rules were formed largely before most folks adopted the use use of the internet in daily lives/practice. Times have changed
Welcome to healthcare when the government foots the bill.
The fact is that the reasonably-trained NP or PA can handle 95% of the patients who walk through a primary care clinic's door. A motivated quack with minimal background could also do well- in 95% of the patients. It is the 5% where knowledge and experience come into play that are the question. If you decide to go with an NP or PA, you are rolling the dice- though there is only a 1 in 20 chance that you will be the worse off for it. Game on?
16
I resent that you are comparing me, with my ivy-league PA degree and 12 years' acute care experience, with a "motivated quack," and imply that as a non-physician, I have no knowledge or experience. I value my NP and physician colleagues, and seek input from them and from RNs and other staff. Every caregiver must be able to determine the limits of his or her ability and seek support when he or she exceeds it, and that goes for physicians, too.
34
For every doctor or other health care provider, there are patients they won't know how to help. That's why we have specialists and a network of providers. The idea that an MD degree guarantees accurate diagnosis and perfect treatment in every case is ludicrous. Most of the MDs I've met cannot handle 95% of cases. Fortunately, there are others to help, others to go to.
1
Steve of Paia: I'm not sure where Paia is, perhaps in Maui, but I would challenge your figure of 95% of patients being treatable by an NP or PA, unless you are talking about a seriously underserved area with few doctors and many sick patients. In most practices in most urban and suburban areas the ratios you quote are off the wall and the odds you imagine are nonsense. Game off.
1
As a sister Nebraskan, raised out here, I hope NP Osburn takes all that compassion and applies it to ranching - by way of not treating her animals as livestock but as the free beings they are.
5
There are enough patients for everyone! The issue becomes, who is responsible. If NP and PA feel confident enough to practice on their own without a MD's input, no problem.! However, 'to whom much is given, much is required.' The $500 to a MD to supervise is nothing in comparison to the lawsuit and malpractice down the road. Everyone have their bad apples, but I think the law tries to 'dumb down' the medical knowledge MDs carry, beyond managing chronic diseases. Knowledge is power and as a primary care physician, who can also perform office procedures, my value will not be diminished. Good luck to the NPs and PAs!
22
Just to clarify, PAs by definition must be supervised by a physician, and the supervisory role the doctor plays varies from state to state. PAs never"practice solo".
1
MD Res in FamMed in Texas: now, you say, "If NP and PA feel confident enough to practice on their own without a MD's input, no problem.", but you certainly don't mean that if an NP and PA feel they can treat your cancer or your diabetes or your lupus, regardless of their confidence, you are not going to allow them to do so, are you?
If NPs want to do the same as doctors with no supervision, fine. As long as they are willing to take on the same malpractice risk as an MD without a "supervising" MD being brought into the suit as well, of course.
105
Actually according to the National Practitioner Database the rate of malpractice cases filed against APNs is SIGNIFICANTLY lower than physicians and studies show patient satisfaction is high. This is publicly available data.
1
I'm surprised that an MD doesn't understand that NPs are independently licensed professionals who carry their own malpractice insurance, particularly if they are in private practice. So, yes, it's "fine."
Has delivering care to patients in need come down to doctors and lawyers????
Paramedics are at the same crossroads as NP's with the medical profession. The AMA has to see both professions as standard bearers for the western medical tradition, not competitors. If the physicians take that tack, they deserve to be sidestepped by offshore telemedicine and marooned in their own fancied entitlements.
As can be seen at elevaed.com, where paramedics are seen as communications officers more than as practical nurses, all healthcare professionals must reject acrimony, close ranks and begin to think of the patients. Building a strong network is the key to everyone's security.
As can be seen at elevaed.com, where paramedics are seen as communications officers more than as practical nurses, all healthcare professionals must reject acrimony, close ranks and begin to think of the patients. Building a strong network is the key to everyone's security.
1
The elephant in the room is that there is a major shortage of trained medical personnel on any level in rural America. We should be offering to forgive the immense debts that doctors incur getting their training so that they will go to these places where they are so clearly needed, but where they can't hope to pay off their med school debts. AND we should be allowing NPs to handle routine care, and to cover shifts. No one should have to go without care because they live in a rural area and there are no doctors around. This whole situation is not OK.
132
NPs/PAs doing primary care, especially in under-served rural areas, generally makes sense. But NPs/PAs practicing solo (i.e. with no oversight) will need liability insurance, which is usually based on risk. How much will their insurance cost relative to MDs who have much more training?
25
If she has one patient who commits suicide and she missed the signs of it, her malpractice insurance bill will probably go through the roof.
1
I have seen NPs on three occasions. Always it was inferior medical care. One had me return twice over a period of months because she thought something might be cancerous, and each time she performed a very painful internal exam. Finally she called in the doctor on the second visit and he said after a one minute exam that it was nothing. So much for months of fear as well.
28
My impression has been that NPs order more tests, and their care is more expensive.
17
Psychiatrists have to go through four years of medical school and then four years of residency. Does Ms. Osburn or anyone else really believe that her nurses program provided her equally training. It's funny that with all the complaints about overprescription of psychiatric medications, we are willing to add more people who have limited training the ability to prescribe these. And, by the way, are opioids also drugs she can prescribe? If so, it's wonderful that we will also be adding to prescribers of these at the time it is felt that too many prescriptions for these are already being given out.
And as to that psychiatrist charging her $500 to supervise her, if anything goes wrong with any of her patients he would be the one sued for malpractice so this doesn't seem an unfair price. Apparently she expects someone else to take on the risks of this for free.
And as to that psychiatrist charging her $500 to supervise her, if anything goes wrong with any of her patients he would be the one sued for malpractice so this doesn't seem an unfair price. Apparently she expects someone else to take on the risks of this for free.
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Does anyone really believe that psychiatrists go into the specialty for the money? If you do, call me, I have a bridge to sell you!
16
$500 a month is $6000 a year, a pretty reasonable fee for official supervision and the type of responsibility involved.
15
What most people reading this don't seem to be getting is that the supervising MD will get pulled into any malpractice suit and by dint of them supervising, will be held responsible much more so than the NP. This is even if the MD never met the patient or even read the chart. By that measure, the money quoted not so much a fee for the doctor's time, per se, but rather a hedge against the risk of a suit, probably to be used to increase the limits on one's own malpractice insurance. By that measure, she was lucky to find someone to do it for $500 a month. That doesn't cover very much malpractice premium, and in exchange, the "supervising doctor" takes on a bunch of personal exposure to liability for patients s/he has never even seen.
Again, if NPs want independent practice, so be it. Just make them get their own malpractice insurance and not be tied in any way to any physician, supervising or not. Take full responsibility and liability for all their own medical decisions and see how it plays out. It's only fair.
Again, if NPs want independent practice, so be it. Just make them get their own malpractice insurance and not be tied in any way to any physician, supervising or not. Take full responsibility and liability for all their own medical decisions and see how it plays out. It's only fair.
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This spectacular disaster has been decades in the making in the watchful eyes of the US Congress and American Medical Association. The well heeled will get medical care. Less wealthy will suffer. Allowing Nurse Practitioners to practice basic medicine does not fill the gap of needing a surgeon in rural and sparsely populated communities. The lead time to mint a doctor is a decade. It will take many years before the medical colleges can educate, hospitals can train, and doctors can serve. US educated and trained doctors also carry hefty debts, making it hard to serve sparsely populated communities. Perhaps it is time to open gates to foreign doctors and require them to serve rural communities for a decade to be free to work anywhere after that.
12
wow!!! When did doctors become the enemy? And turf war?? Clearly this is written by someone who isn't in the medical field. NP & PA certainly have a role in providing care with supervision from a MD/DO, because they have less knowledge & clinical experience than a 4th yr medical student. And saying "They can do what I can do;" is all fine & dandy when it's an ear infection or UTI. When it's uncontrolled DM or schizophrenia masking as bipolar, make sure u know enough to consult. As a MD, I've seen enough hubris & arrogance on the part of NP & PAs to say sometimes they know just enough to be dangerous. Arrogance & hubris is blissful until it isn't!
56
Please.....You can find arrogance and hubris in doctors too. I have been misdiagnosed by MDs as well. From my perspective you sound like you are starting a turf war. It is obvious to everyone our healthcare system is failing. Until more doctors are willing to live in underserved communities - NP & PAs will have to fill in the gaps giving good care as well as less than ideal care. I know no profession were all the practitioners are infallible.
30
Ah Oregon...I'm not starting a turf war; I'm stating a fact; NPs have less training therefor should need supervision just like a resident. As I said NPs/PAs provide a valuable service, but as another commentator mentioned they will not fill a gap or be cheaper! The healthcare system has a shortages, but if a NP can just set up shop, why can't the medical student?? Why does the CEO of insurance companies require 28million?? I don't have all the answers but unsupervised NP isn't always the stop gap u think it is? Again...when did physicians become the enemy!
17
Many MDs don't care to move to the places that have come to depend on non-physicians for medical care. Here in semi-rural central New York, where first-year physicians come in at a $500,000 first-year combined salary/benefits/profit-share, hospitals have trouble recruiting. The article doesn't mention that in such places, early-mortality rates are often high, hospital safety ratings are frequently iffy, and patients harmed by medical incompetence/neglect have little legal recourse, because, basically, the low standard of care becomes its own defense. Would under-served areas be better off with actual doctors doing the primary care, the psychiatric assessments and sessions, the first-contact referral visits? Of course. How would you make that happen?
34
I am a primary care nurse practitioner. I love what I do and I give my patients the best care I possibly can. I look forward to the day when New Jersey also allows me to practice to the full extent of my training, without a signed collaborative agreement with a physician. I do not pretend I am a physician. I do not pretend to know everything, and I am glad to work with a smart doctor who enjoys sharing knowledge, on those occasions when I get a really complicated case. But yeah, I can manage chronic illness like diabetes, hypertension, COPD, etc. pretty darn well. I can treat many kinds of infections. I can do lots of stuff, and do it with joy and attentiveness. There are many days when the physician and I say "Hi" and "Bye" and not much more, because we are both busy treating patients all day, and I don't have an issue that requires his input. Let's face it: physicians are leaving primary care to NPs more or less by default, because so few of them graduate wanting to be PCPs any more. And psychiatrists? Around here, many of them simply do not take insurance any more. My patients cannot afford $300 office visits every time. So they come to see me for their depression and anxiety. And I am glad to refer them to psychiatric NPs for their more complicated mental health issues.
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Darling I'm sure u can manage those things but I said complicated, not chronic. Let's not confuse the issue! Furthermore, even I, a specialist can manage chronic issues and so can most medical students! The reason most physicians aren't going into primary care is b/c of low reimbursement compared to the amount of time required for patient care. And let's face it ur cheaper b/c u have less debt, and let's not tiptoe around the the other elephant in the room...malpractice. Who do u think will get sued if u make a mistake..,the doctor. Be careful what u wish for...u want o practice w/o supervision make sure u get great malpractice coverage! NJ/NY have high malpractice rates. Like I said "arrogance & hubris", well until the lawyers get involved!
7
Darling I'm sure u can treat chronic conditions; so, can most medical students! I said complicated, and let's not forget the elephant in the room...debt. You are cheaper b/c u have less debt, where as a MD/DO, spends 4yrs in medical school in addition to residency lasting from 3-5yrs, so if u honestly think you know more than a resident then you don't know enough to know what u don't know! And the other elephant, malpractice! If u make a mistake, who gets sued...the doctor! Be careful what u wish for and make sure u buy enough liability if and when NJ drops that pesky MD/DO supervision!
11
Whoa! T, I was going along here basically agreeing with you almost entirely until you decided to call her "darling." Are you flipping kidding me. This is 2015 and the nurse is not your darling! You have made me reconsider what is behind the resistance to the NPs' scope of practice.
23
I've gotten great care from nurse practitioners. My current primary care provider is a nurse practitioner. There's a doctor in the practice, but I've only seen the doctor once, several years ago.
14
Another obstacle to fuller utilization of NP's is insurance plans: For instance, Blue Shield California no longer contracts with Nurse Practitioners, so all NP visits are out of network, and therefore cost the patient more.
12
The first time I saw a nurse practitioner in a doctor's office, I thought I'd died and gone to medical heaven. She was thoughtful, gentle, took her time to explain everything that she was doing. I also give credit to my doctor for hiring her - he was not afraid of the competition but rather saw the NP as a logical extension of good care. Cudos to Nebraska for passing this law, to Ms. Osburn for her perseverance.
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A key component to the NP dilemma is referrals. Health care is comprised of many levels of needs. How many of us feel weird going to a doctor for something that could well and easily be taken care of by an NP.
That is when healthcare is going to be successful - work together docs, not separately. Own up to the fact that NP's have their place and so do docs.
NP's that I have seen are more than willing to make a referral to a doctor when needed.
Obviously the nursing profession is much more apt and progressive in finding solutions to cost, care, and policy than the medical profession. What does that say??????? Now, who would you rather have take care of you for many of your ailments? And a most interesting question - why or why not?
That is when healthcare is going to be successful - work together docs, not separately. Own up to the fact that NP's have their place and so do docs.
NP's that I have seen are more than willing to make a referral to a doctor when needed.
Obviously the nursing profession is much more apt and progressive in finding solutions to cost, care, and policy than the medical profession. What does that say??????? Now, who would you rather have take care of you for many of your ailments? And a most interesting question - why or why not?
15
These doctors' comments are pure turf-guarding. Saying nurses practicing would "further compartmentalize and fragment health care...." is a fancy way of saying "we want the whole treatment team approach with the physician as head dog.
I'm a Licensed Psychiatric Social Worker. Yes, it's great if you have a team to collaborate with 24 hours a day. But even I've been on my own late at night doing Crises Intervention out in the middle of nowhere. It's downright dangerous sometimes.
But today's reality is: there is a shortage of physicians (actually General Practitioners). Most doctors specialize so they make the most bucks. Nurse Practitioners can do what GP's do. And I'd venture to say most E.R. Trauma Nurses can diagnose patients as well as 1st or 2nd year Residents.
The solution was to elevate Nurses to a true Practitioner role. And with technology, anyone in Nebraska can connect with a surgeon at John's Hopkins for consultation.
When I was doing Crises Intervention, there were no cell-phones, no Skype, no PC's. You wore a pager, and then found a payphone to page a Psychiatrist on call.
This reminds me of the ruckus out in California when Dental Hygienists wanted to open independent practices. But the Dental Association balked saying they needed to approve every teeth-cleaning done.
As the article says, "Do you see a Psychiatrist around here? I don't!"
I'm a Licensed Psychiatric Social Worker. Yes, it's great if you have a team to collaborate with 24 hours a day. But even I've been on my own late at night doing Crises Intervention out in the middle of nowhere. It's downright dangerous sometimes.
But today's reality is: there is a shortage of physicians (actually General Practitioners). Most doctors specialize so they make the most bucks. Nurse Practitioners can do what GP's do. And I'd venture to say most E.R. Trauma Nurses can diagnose patients as well as 1st or 2nd year Residents.
The solution was to elevate Nurses to a true Practitioner role. And with technology, anyone in Nebraska can connect with a surgeon at John's Hopkins for consultation.
When I was doing Crises Intervention, there were no cell-phones, no Skype, no PC's. You wore a pager, and then found a payphone to page a Psychiatrist on call.
This reminds me of the ruckus out in California when Dental Hygienists wanted to open independent practices. But the Dental Association balked saying they needed to approve every teeth-cleaning done.
As the article says, "Do you see a Psychiatrist around here? I don't!"
70
Do you see a neurosurgeon around there either? Why would expect a specialist in an area of the country with such a low population density? This part of the argument is dumb.
6
Many RNs are much smarter in their specialty area than interns & 1st year residents. But they also have the benefit of a collaborative community of expertise in acute hospital settings & offices. No intern or 1st year resident would ever want to practice in desolate Nebraska alone ! The central nervous system is a major organ; dysfunction coccurs for many reasons. Psychiatry is not just about kindness.
Suicidality, serotonin syndrome, diabetic crises, ODs, TIAs, madication toxicity, etc are not simple to manage.
Suicidality, serotonin syndrome, diabetic crises, ODs, TIAs, madication toxicity, etc are not simple to manage.
The reason is that there is a shortage of psychiatrist is that it is one of those low paying specialties that most American med school graduates refuse to go into. In fact, if it wasn't for foreign medical school graduates, many of whom struggle to speak English well, psychiatry residencies would be empty.
Oh, and when The Times publishes stories such as this saying a nurse degree is equal to four years of medical school and four years of residency (and even more if one specializes in something like child psychiatry) it certainly doesn't entice students into wanting to enter the field.
Oh, and when The Times publishes stories such as this saying a nurse degree is equal to four years of medical school and four years of residency (and even more if one specializes in something like child psychiatry) it certainly doesn't entice students into wanting to enter the field.
2
I have been a family doc for 26 years. A few comments:
1. Nurse practitioners and physician assistants can do most of what I do. Physicians are over-trained for ear infections and stable diabetes. I could teach anyone at this blog to freeze warts.
2. NPs and PAs are more likely to have trouble with difficult cases, so immediate outpatient consultation (a doc on the premises, working with several NPs/PAs) makes clinical sense. It is unlikely to happen much. Corporations generally want doctors to have a full schedule in addition to helping out the other folks. This makes for a lousy job for the doctor.
3. It depends on the field. NPs/PAs should not be orthopedic surgeons or radiologists.
4. Docs are fighting a losing battle in some of the easier fields, like psychiatry or prim. care. Psychiatrists do not put stents into coronary arteries in the middle of the night.
5. Over time, more and more docs will gravitate to the harder, more lucrative specialties and "going to see the doctor" will become less common. Some patients will resist but more will be ok with it. Heck, the NPs in our clinic are called doctor now.
6. If an NP is willing to go to isolated area, most docs won't be worried about that.
7. None of this will save any money. The income of family docs is a couple percent of total health care spending.
8. NPs/PAs will drive out docs. Why should a med student spend 7 years in primary care training to be considered the equal of a nurse?
1. Nurse practitioners and physician assistants can do most of what I do. Physicians are over-trained for ear infections and stable diabetes. I could teach anyone at this blog to freeze warts.
2. NPs and PAs are more likely to have trouble with difficult cases, so immediate outpatient consultation (a doc on the premises, working with several NPs/PAs) makes clinical sense. It is unlikely to happen much. Corporations generally want doctors to have a full schedule in addition to helping out the other folks. This makes for a lousy job for the doctor.
3. It depends on the field. NPs/PAs should not be orthopedic surgeons or radiologists.
4. Docs are fighting a losing battle in some of the easier fields, like psychiatry or prim. care. Psychiatrists do not put stents into coronary arteries in the middle of the night.
5. Over time, more and more docs will gravitate to the harder, more lucrative specialties and "going to see the doctor" will become less common. Some patients will resist but more will be ok with it. Heck, the NPs in our clinic are called doctor now.
6. If an NP is willing to go to isolated area, most docs won't be worried about that.
7. None of this will save any money. The income of family docs is a couple percent of total health care spending.
8. NPs/PAs will drive out docs. Why should a med student spend 7 years in primary care training to be considered the equal of a nurse?
166
Comments that are rational, economically savvy, and probably distressing to some. To say that a hailstorm is coming isn't to like the prospect. Vbering is a reasonable person here.
2
1) NPs can do ALL that you can do and sometimes better. Ask patients who they prefer? NPs...because they LISTEN.
2) NPs can handle heart attacks, major trauma when they work in rural settings. They get called out to farms to handle terrible equipment trauma.
3) NO NP wants to be an orthopedic surgeon or a radiologist! That’s just a silly remark. BUT they do read x-rays and splint and cast broken bones. Rural patients don’t have the money to get into an orthopod for every sprain or break. They can read pneumonia and congestive heart failure on x-rays.
4) Psych and primary care are easy? Psychiatrists putting in heart stents? What? Family practice NPs in rural areas deliver babies, suture, care for chronic disease that isn’t always stable--diabetes, heart disease, high blood pressure.
5) I don’t know any self-respecting NP that allows a patient to call her doctor.
6) And yes the entire point of this article is that NPs are desperately needed in “isolated areas” because MDs say they can’t make enough money. NPs do it for service..NOT money.
7) This DOES save money! NPs charge less and despite what doctors such as you say...they do NOT refer all patients to specialists. If an NP can work with a patient with beginning high blood pressure or early diabetes, it sure beats a VERY ill patient in a diabetic coma or stroke being airlifted to a trauma center!
8) NPs do not drive out doctors. We fill an important part of medicine...primary care.
2) NPs can handle heart attacks, major trauma when they work in rural settings. They get called out to farms to handle terrible equipment trauma.
3) NO NP wants to be an orthopedic surgeon or a radiologist! That’s just a silly remark. BUT they do read x-rays and splint and cast broken bones. Rural patients don’t have the money to get into an orthopod for every sprain or break. They can read pneumonia and congestive heart failure on x-rays.
4) Psych and primary care are easy? Psychiatrists putting in heart stents? What? Family practice NPs in rural areas deliver babies, suture, care for chronic disease that isn’t always stable--diabetes, heart disease, high blood pressure.
5) I don’t know any self-respecting NP that allows a patient to call her doctor.
6) And yes the entire point of this article is that NPs are desperately needed in “isolated areas” because MDs say they can’t make enough money. NPs do it for service..NOT money.
7) This DOES save money! NPs charge less and despite what doctors such as you say...they do NOT refer all patients to specialists. If an NP can work with a patient with beginning high blood pressure or early diabetes, it sure beats a VERY ill patient in a diabetic coma or stroke being airlifted to a trauma center!
8) NPs do not drive out doctors. We fill an important part of medicine...primary care.
124
4. Primary care, an easy field? That is the field where your breath of knowledge needs to be the vastest.
8. Nurse practitioners and PAs in CA can make $100 - 140K a year, no strings attached, less liability. Why go to medical school? A primary care doctor will make less or not more.
8. Nurse practitioners and PAs in CA can make $100 - 140K a year, no strings attached, less liability. Why go to medical school? A primary care doctor will make less or not more.
3
Good! One of the best "doctors" I have had in my nearly 79 years is a nurse practitioner.
34
One more chink in the "Doctor as God" fortress. It's about time the AMA lobby was slapped down in the quest for more money for MDs. Kudos to Nurse Practitioners, who provide skilled, affordable, person-centered care!
83
Well, dgojill of Durango in the Congo, like it or not, the AMA, despite its shortcomings, serves a useful function in the advancement of American medicine. And when you have your heart attack or stroke you will only be too eager to have the best PHYSICIAN available treating you, not an NP or PA despite all their skill, affordability, and personableness.
5
Wow! Murlene Osburn gets my total approval for her resourcefulness and smarts, as well as calling out the truth!! She saw the need, she is taking steps to fill it. And that's in addition to her "real" work as a rancher. This fight is truly only about competition and the medical practices that "real" doctors don't want to fill or manage. This is just another sad example of the MD Cartel still trying to have its way and win at all costs. Meanwhile, real people in real towns and real rural areas in so many states are suffering and need care. Glad to see change is truly coming.
137
As an NP I know I am not a doctor, I do not pretend to be a doctor. Nevertheless, patients and families will frequently tell me they are much more comfortable and happy with my care after the bad experiences they have had with multiple doctors in my field.