Could an FPNP start an operate a "cash only" walk in... - page 2

clinic without a doctor onsite? If I couldn't become a CRNA I think that this would be my secondary goal. When I was a Corpman in the Navy I dreamed of going to medical school and gaining a Family... Read More

  1. by   Dave ARNP
    I completely agree. Pain is the best!

    Not much on passing gas, but I think MDA's do a pretty decent job of pain mgmt. (I can't brag TOO much )

    Dave
  2. by   Tenesma
    roland,

    anti-platelets, statins, ACE-I, beta-blockers have long been part of multi-drug therapy for anybody with ischemic cardiac disease.... at least for the patients I take care of.... however, peri-operatively we stop anti-platelet drugs, statins and ACE-I and try to maximize the beta-blockade, and then restart all four drugs about 24-48 hours post-op.

    the problem with western research is that 80% of pharmaceutical/medical device research is supported by private industry, and therefore when you read a journal you will only see articles supporting drugs... For example, when was the last time you read a journal article where they showed that a certain drug is actually detrimental??!! very rare...

    here is an interesting tid-bit: did you know that americans spent MORE on alternative medication/treatments than on "western" medicine!!!! by 2 billion or so....
  3. by   SharonH, RN
    Quote from Roland
    clinic without a doctor onsite? If I couldn't become a CRNA I think that this would be my secondary goal. When I was a Corpman in the Navy I dreamed of going to medical school and gaining a Family Practice specialty. With such a degree, I felt that I could "bring back" MD housecalls to America even if I couldn't accept insurence. Well, it doesn't look like becoming an MD is realistic (right now getting my BSN is plenty of a challenge) so I was considering the "legal" feasibility of pursuing this concept with the NP license. I feel certain that I couldn't make "house calls", but how about a walk-in, cash only clinic (that would have a "sliding scale" fee arrangement based on income, and take payments)? Would physician supervision requirements be such that I would have to have an MD onsite? If not what sort of supervision would be required (and what sort of "split" would be typical). I would also like to be able to integrate alternative and complementary medicine that had significant science supporting its efficacy. Is this something that NP's are typically able to do within their "scope" of practice? I've had MD's tell me that THEY would like to utilize more A&C approaches, but fear professional ridicule (thus I suspect that it would be even HARDER for NP's to integrate such approaches).

    Roland,


    In reply to your original question: Yes it can be done and it is being done. Nurse Practitioner magazine does an annual legislative review in their January issue. It summarizes the scope of practice and legal and regulatory requirements for each state's NPs. If you can find a copy of the January issue, it will tell you what is legal in your state and give you an idea of what your options are.
  4. by   zenman
    how about we compare the death rates with western medicine and without western medicine:

    1) a patient comes in with dense hemiplegia and a history of a-fib... do we treat him with western medicine (thrombolytics?) or do we watch his stroke become permanent.

    2) a patient comes in in a coma after a fall - do we provide decompression for a subdural bleed or do we watch him die?

    3) a patient comes in with end-stage liver failure - do we provide him a liver transplant - and bridge him with a liver machine?

    4) a neonate is born with a diaphragmatic hernia - ???

    5) a septic nursing home patient with a UTI - ???

    don't give me this crap about western medicine having a higher death rate than alternative medicine.... that is like comparing morbidity/mortality of the treatment modalities of ventricular rupture vs. "achy" elbow...

    and zenman - don't get all high and mighty - i think the OP has some good points, that are worth discussing...
    This can remain in NP forum if you wish as I've wondered when NPs might consider some more alternative medicine approaches particularly since more is spent, even out of pocket on alternative medicine than all other forms of medicine...do you hear the public evaluating western medicine here? Now, I'm familiar with all the blow-holes that take advantage of all the poor unsuspecting people out there. I'm saying "integrate" what works from both systems. Eastern forms of medicine have been around for thousands of years and have a track record...both effective in some cases and not in others. Western medicine has been around a few hundred years and in the USA we are now ranked 37th in the world (right behind Cuba with a lot of alternative medicine available to its people). Basic public health has been responsible for more lives saved than all th fancy approaches in medicine and surgery. Of, course in an emergency I will choose the modern ED. However, western medicine has failed miserably with chronic diseases. I have a standing offer out for any western medical practitioner to parachute naked with me into any jungle with no medical equipment whatsoever and see who can be most successful in treating the tribe. I even treated a little lady in Mexico during a medical mission trip who was, according to the NPs, having a heart attack. She refused to go to the hospital as they never did much there anyway. Should I tell you how amazed the NPs where? Nah, I'm too humble...LOL! Should I tell you that I no longer have bilateral tennis/golf elbows after being in misery for a year and having no treatment option left but surgery? Should I tell you that my wife, who has fibromyalgia, has earned a third begree black belt in Hapkido...and not just with western medicine help? Would you like some references from the MDs I treat...including a chief of orthopedic surgery, internal medicine guys, and physical medicine, to name a few. There's nothing "high and mighty" about me, I just use what works-be it western or eastern approaches. That's what our patients deserve. Answer my question as it is legit, how many people are killed yearly by western practitioners sworn to do no harm? Now, when and if you have practical experience in both western and eastern forms, all I'll be hearing from you is probably an opinion...but that's ok, I guess. :chuckle
  5. by   Tenesma
    zenman:

    you are confusing a lot of points in one paragraph

    1) my primary practice is "western" medicine, but as part of my pain practice i rely on "alternative" medicine: acupuncture, behavioral modification, etc..

    2) comparing length of existence is not a valid point: eastern medicine has been around for a long time, and it has a poor track record. Like you said, the biggest changes in global health have been public health issues (sanitation, urban reorganization, hospital hygiene, washing hands, smoking cessation) and those all stem from "western" culture. Just because people have been drinking chicken blood for abdominal cramps for thousands of years, doesn't lend more credibility to eastern medicine - superstition is a dangerous thing

    3) when you say that we are ranked behind CUBA - what statistic are you using??? that is just plain ridiculous - and I have been on a medical mission to CUBA - so i saw it first hand.

    4) western medicine has failed with chronic diseases... you gotta be kidding me!!! the reason why we have chronic diseases is because "western" medicine has allowed for people to live beyond 35 years of life!!!! how many chronic diseases would a 28 year old have??? now that we have extended their life expectancy of course there are going to be more chronic diseases
    a) life expectancy in 1900 in China was 25 while the life expectancy at the same time in the US was 48.
    b) life expectancy in 1950 in China was 35 while in the US it was 73
    c) 2/3 of deaths in China were due to infectious diseases - what did their alternative medicine do to help with that? again: sanitation and antibiotics

    5) jumping into the jungle - what? western medicine relies on medication and medical devices, therefore you could never compare western medicine and eastern medicine in that setting as you would be depriving the western practitioner of their devices. I would argue that if you and I jumped into the jungle and performed a double-blinded, randomized trial we would have the exact same mortality rate for our patients

    6) i am glad that you were able to cure/treat your elbows, your wife and orthopedic surgeons.... how can you use that as evidence that eastern medicine is better - especially since your first post was alluding to the higher death rate with western medicine... which brings me to my next point

    7) "how many people are killed by western practitioners?" - first of all that is an inflammatory statement, since the patients that you are alluding to died of medical errors and complications, and were not intentionally "killed".
    - and yes, there is a high number of patients who have died in hospitals due to negligence/errors/complications/device-malfunctions etc, but you would have to compare the general population mortality rate with AND without access to a hospital/"western" practitioner... and you will find that the deaths are a small price to pay for the number of lives saved by western practice. a good example of this would be vaccination, there are annual deaths due to side-effects of vaccines or reactions to the vectors/stabilizers in the vaccine, but that has to be compared to the number of deaths that would have occured without the vaccine

    So, in totum, I agree that an ideal practice of medicine would be the integration of western medicine with the best that eastern medicine has to offer (something i practice already), however, you can't be making generalizations that are erroneous, misleading and just ill-conceived.
  6. by   zenman
    zenman:you are confusing a lot of points in one paragraph
    Not confused; just throwing a lot out there.

    1) my primary practice is "western" medicine, but as part of my pain practice i rely on "alternative" medicine: acupuncture, behavioral modification, etc..
    Please tell us what you do.

    2) comparing length of existence is not a valid point: eastern medicine has been around for a long time, and it has a poor track record.
    Length of existence is valid. One has been around a long time; the other has not. Re: "track record"-is the "track record" of our current health system the reason more visits and more money is spent on other systems! The public is speaking...hello!

    3) when you say that we are ranked behind CUBA - what statistic are you using??? that is just plain ridiculous - and I have been on a medical mission to CUBA - so i saw it first hand.
    Then you need to see first hand the results of the "ridiculous" World Health Organization study.

    4) western medicine has failed with chronic diseases... you gotta be kidding me!!! the reason why we have chronic diseases is because "western" medicine has allowed for people to live beyond 35 years of life!!!!
    The blood has run from my face and I'm getting nauseated! You are a healthcare practitioner and are not up with the latest info. Are you practicing ethically? Of course there are more chronic conditions as we live longer and longer and lie there in our nursing home bed in misery. However, chronic conditions occur in all age groups. Please do a search on your favorite search engine before going back to work...this is old news! While you might be the one person on the face of the earth that believes as you do: "A majority of physicians, policy makers, and the public are concerned that the nation's health care system does not address the needs of people with chronic medical conditions, according to the results of surveys conducted by the Johns Hopkins Bloomberg School of Public Health." Please catch up before you go into the office Monday morning.

    5) jumping into the jungle - what? western medicine relies on medication and medical devices, therefore you could never compare western medicine and eastern medicine in that setting as you would be depriving the western practitioner of their devices.
    Yes, when the electricity is turned off, western medicine is too...LOL!

    6) i am glad that you were able to cure/treat your elbows, your wife and orthopedic surgeons.... how can you use that as evidence that eastern medicine is better - especially since your first post was alluding to the higher death rate with western medicine... which brings me to my next point
    A Korean needle-sticker fixed my elbows. Left one in one visit, right one on the second visit. Don't get confused; I didn't say one was better than the other. Each has their good and bad sides.

    7) "how many people are killed by western practitioners?" - first of all that is an inflammatory statement, since the patients that you are alluding to died of medical errors and complications, and were not intentionally "killed".
    - and yes, there is a high number of patients who have died in hospitals due to negligence/errors/complications/device-malfunctions etc, but you would have to compare the general population mortality rate with AND without access to a hospital/"western" practitioner... and you will find that the deaths are a small price to pay for the number of lives saved by western practice.
    Sorry, didn't mean to make an inflammatory statement as that is so unlike me. Intentionally killed or not...you are pretty darn dead; I'll tell the family we're sorry that is it just part of the system!

    So, in totum, I agree that an ideal practice of medicine would be the integration of western medicine with the best that eastern medicine has to offer (something i practice already), however, you can't be making generalizations that are erroneous, misleading and just ill-conceived.
    However, we have now established that you have not kept up with what is going on in the real world so regarding my "erroneous, misleading and just ill-conceived" generalization...well, what can I say?
  7. by   Roland
    I think that many "conventional" practitioners would say that CAM is fine so long as it is subjected to the scientific process. Otherwise, HOW can we be certain that the results that a particular intervention seems to be generating are indeed attributable to that intervention? Of course one of the problems at least in my opinion with our current process is that it is next to impossible to get these interventions tested in a economical, fair, and impartial manner. I know that the National Insititute of Health had a CAM division created several years ago (they lectured at my school), BUT it is not funded to any significant degree in relation to the agents/interventions that need to be tested. Pesonally, I think that either the FDA clinical trial process needs to be revamped with an eye on making it quicker, and less expensive (to test new agents and methods) or Western Medicine needs to develop protocols short of the FDA clinical trial process where they will recognize the effectiveness of CAM interventions (when warranted). Consider that ASPIRIN is only now being seriously evaluated for its anticancer properties despite more than fifty years of research suggesting it's possible/likely efficacy. I would suggest that because aspirin doesn't lend itself to becoming the next IRESSA/genfitnib (meaning that it can't be patented and then priced at almost $2,000 per thirty day dose) there has been little incentive to evaluate the drug for this purpose.
    Last edit by Roland on Feb 23, '04
  8. by   Dave ARNP
    Roland,
    If you disagree so much with western medicine, why on earth are you in advance practice nursing?

    Western medicine IS what we practice, ya know

    Dave
  9. by   Roland
    MD Term, how did you get the impression that I disagreed "so much" with "Western medicine". I felt that my last post was a polite, measured (and unfortunately probably weak) response to Zenman's allegations. It is true, that I believe that many CAM therapies have merit and should be integrated more into clinical practice (as do thousands of M.D.'s including apparently Tenesma since he/she mentioned that he integrated aspects of CAM such as acupuncture into his practice). What disturbs me is the long delay that often occurs (and sometimes it's more than a delay) between substancial, empirical evidence for certain therapies and the implementation of this knowledge into clinical practice.

    I can remember back in highschool (I think it was 1987) doing a Biology project on the scientific evidence for the role of Helicobacter Pylori in the etiology of peptic ulcers and the possible use of antibiotics in their treatment. The teacher gave me "B" in spite of what she said was one of the finest papers she had ever read by a highschool student, because she said that such theories were in her words "far outside the mainstream of serious science". Now the sources that I quoted for the paper dated from as far back as 1955 to as recent (relative to 1987) as 1986 and many were articles from peer reviewed journals. Of course H. Pylori is NOW accepted as perhaps the LEADING cause for peptic ulcers. However, any Dr. or NP treating peptic ulcers with antibiotics in the 80's was probably labeled "out of the mainstream" or worse a quack.

    I have been reading each volume of Harrison's virtually cover to cover from before the time that I even had acne and most of what little I know about medicine comes from "Western sources". I would say that my approach to the issue approximates the M.D.'s and N.P.'s over at Lef.org. However, I am critical of the fact that they also SELL supplements as I believe that this creates an intrinsic conflict of interest (on the other hand if they didn't do this it would probably be impossible to fund their activities without major grants which would ALSO compromise their credibility).
    If there was an "attack" on Western medicine it didn't come from me as I believe that our medical system is the finest in the world. That doesn't mean however that there isn't room for improvement! Also, I AM NOT an NP although it is possible that I may one day become one with God's grace.
    Last edit by Roland on Feb 23, '04
  10. by   Dave ARNP
    I didn't mean to imply any disrespect.

    I think your willingness to question will make you one heck of a NP.

    -Dave
  11. by   Tenesma
    Zenman: I will re-address your points and let's see if you can make some rational responses to some of them...

    1) the ranking you are referring to is the WHO Health Systems review - which bases its ranking on the following criteria:
    A) fairness of financial contribution/distribution of financing: it reflects the relative amounts of money taken from the rich and the poor to finance a country's health system. If a lot is taken from the rich and little or nothing from the poor, the financial distribution is considered "fair." The greater the inequality in amounts taken from rich and poor, the higher the indicators get (based on that specific sub-component alone Columbia is ranked as the best in the WORLD!!!)
    B) distribution of health: this assesses inequalities in the health of rich and poor, as well as in the health care given to rich and poor. A high score is achieved if similar levels of health and health care service exist for both groups.
    So in summary this ranking will reward those countries that have the most socialized medical system... so yes, you are right: the US is less socialist than CUBA!!!! If you are sick where would you rather go: United States or Andorra/Malta/Oman/Greece/Columbia/Morocco/Chile/Dominica/Costa Rica/Cuba (all of these had higher rankings based on that useless ranking system)
    You have done little to prove that western medicine is not serving us well, just because we have a less socialized health care system.

    2) chronic disease: now that you agree that it is thanks to western medicine that we actually have a longer life expectancy and thus have unveiled chronic diseases that were until recently unknown because nobody ever lived to see Alzheimer's/Coronary heart disease/Emphysema develop.... How can you say that we have failed with chronic diseases??? we have made stunning progress... Can you give me any examples of how "eastern" medicine has provided any assistance whatsoever with any of our chronic diseases... IE: insulin-dependent diabetes, Myopia, myasthenia gravis, hypothyroidism, asthma, etc... the list goes on. So don't use chronic disease as an example... Your quote from Hopkins is accurate: the focus of western medicine has been more on the management of exacerbations of chronic disease rather than prevention/treatment of chronic disease. And yes, it is frustrating. But partially this can be blamed on patients - no matter how well you educate them... here is an example: who will go to see their doctor 1) the patient with chest pain due to an MI or 2) the patient who is slowly building up plaque in his coronaries??? I can make the example even simpler, who works out in this country, despite the fact that EVERYBODY knows that physicial exercise is good for you...

    3) you didn't address my statement regarding number of deaths due to complication/medical-medication errors in "western" medicine.

    4) length of existence: you couldn't explain to me why just because one system has been around for 3,000 thousand years that it has a better track record. Women were considered 2nd class citizens for thousands of years - so I would suspect that you woulg argue in favor of keeping them that way?
    "eastern" medicine has NO or MINIMAL track record, as there is scant documentation of anything... It wouldn't be a very expensive study... The only "eastern" medicine that has any documented benefit so far is acupuncture/pressure... and that has become mainstream.

    5) the most interesting point you made so far: "Of, course in an emergency I will choose the modern ED"... I find it interesting that when your life is truly in peril that you would choose "western" medicine, but that when your patients are complaining of an achy elbow you recommend "eastern" medicine - so you can make a few bucks and if it works great (the placebo effect is truly astonishing) great, and if it doesn't work - you can sleep at night, because they aren't going to die from it.

    6) what do i do? not that it really matters in this conversation, because it shouldn't alter any of the validity of my points. I am an anesthesiologist who works in the OR/Surgical ICU and pain management on the side.
  12. by   zenman
    Posted by tenesma: what do i do? not that it really matters in this conversation, because it shouldn't alter any of the validity of my points. I am an anesthesiologist who works in the OR/Surgical ICU and pain management on the side.
    Thanks; it does matter. Years ago in Speech class I was taught to address your speech to the audience. In nursing school, I was taught the same thing in therapeutic communication.

    You have done little to prove that western medicine is not serving us well, just because we have a less socialized health care system.
    I think that the World Health Organization should have a few people who know what they are doing. I don't expect everyone to agree with anyone, though! You do have a problem though if you think that our health care system is serving us well. The newpapers (rags that they are) have articles everyday. I don't have to "prove" anything; there are plenty of others, physicians included, who agree that the system is broken.

    chronic disease: now that you agree that it is thanks to western medicine that we actually have a longer life expectancy and thus have unveiled chronic diseases that were until recently unknown because nobody ever lived to see Alzheimer's/Coronary heart disease/Emphysema develop....
    Course I agree with this.

    How can you say that we have failed with chronic diseases??? we have made stunning progress...
    I don't come up with this stuff. I just read the same journals you should be reading.

    Can you give me any examples of how "eastern" medicine has provided any assistance whatsoever with any of our chronic diseases... IE: insulin-dependent diabetes, Myopia, myasthenia gravis, hypothyroidism, asthma, etc... the list goes on. So don't use chronic disease as an example...
    Western medicine medicine has a better record with acute conditions, trauma, surgery, etc.; Eastern Medicine with it's none-reductionistic approach has a better record with chronic diseases. Please don't ask me to look up anything else for you!

    Your quote from Hopkins is accurate: the focus of western medicine has been more on the management of exacerbations of chronic disease rather than prevention/treatment of chronic disease. And yes, it is frustrating. But partially this can be blamed on patients - no matter how well you educate them...
    This is part of the failure of our health system...prevention/treatment. I agree that patients fail also, but where are our skills in getting them to comply?

    I can make the example even simpler, who works out in this country, despite the fact that EVERYBODY knows that physicial exercise is good for you...
    I do; I'm a 53 year old hunk! BP 106/52, P 54. 210 pounds of lean Texas meat.

    you didn't address my statement regarding number of deaths due to complication/medical-medication errors in "western" medicine.
    I didn't; what exactly was it?

    length of existence: you couldn't explain to me why just because one system has been around for 3,000 thousand years that it has a better track record. Women were considered 2nd class citizens for thousands of years - so I would suspect that you woulg argue in favor of keeping them that way?
    "eastern" medicine has NO or MINIMAL track record, as there is scant documentation of anything... It wouldn't be a very expensive study... The only "eastern" medicine that has any documented benefit so far is acupuncture/pressure... and that has become mainstream.
    Don't know if I said Eastern medicine has a "better" track record; it has just been around longer. I do find it interesting that more money and visits are spent on "alternative" medicine. Does that say anything about any track record? Or am I confused? Course most of my clients and the clients at the Academy of Oriental Medicine where I taught were "western medicine failures"...and that was one busy place!

    the most interesting point you made so far: "Of, course in an emergency I will choose the modern ED"... I find it interesting that when your life is truly in peril that you would choose "western" medicine, but that when your patients are complaining of an achy elbow you recommend "eastern" medicine - so you can make a few bucks and if it works great (the placebo effect is truly astonishing) great, and if it doesn't work - you can sleep at night, because they aren't going to die from it.
    Like I said earlier, Western med for acute conditions; Eastern when your chronic conditions have not improved with Western approaches. What's so interesting about that? My "more than achy" elbows had already been through the western health care system and the next step was surgery. Two sessions of acuupuncture (free to me) was a much more desirable approach. And yes, no one has died on my table.
  13. by   Tenesma
    so zenman,

    it looks like we agree on a few points

    1) prevention/education is key
    2) we need to merge the good components of both western and eastern medicine
    3) our medical/nursing education should have a larger component dedicated to health education/prevention, nutrition, proven "alternative"/"eastern" medicine - for a more holistic approach
    4) that you would rather have me at your bedside when you are close to death, and that i would rather have you at my bedside for "chronic" unresolving ailments


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