MD, DO, NP, DC, OD -- Who deserves the title PCP?

Specialties NP

Published

our professional scope of practice asserts that our role is to assess, diagnose, and treat in health and illness - head to toe, physical and behavioral.

from assessing, diagnosing, treating - diabetes, thrombosis, heart disease, infection, emphysema, hep c, hiv, etc, to rendering prenatal care, and preventative care - we are primary care providers. we make life and death decisions each day with our patients in managing disease - thrombosis management and prevention; hep c management; hiv management, heart disease and cva management; women's health - yet we are given less legitimacy in the social security act and cms section 410.20 than a chiropractor or optometrist.

i have nothing against chiropractic physicians mind you, but take a look at chiropractic.

cannot prescribe - not even an aspirin

procedures? - scant more than "moist heat";

assessment - can't even look into your ear according to their scope of practice

educational requirements? - a bachelors degree?, nope - about a year and a half of college study (90 credits), a 2.5 gpa, and 3 yrs of study at a chiropractic school.

how do chiropractors see themselves? go to http://schools.naturalhealers.com/lifewest/

chiropractic is a total-body healthcare system, and not a method of pain management. as a gatekeeper for direct access to the health delivery system, the responsibilities of the doctor of chiropractic as a primary care clinician include wellness promotion, health assessment, diagnosis, and the chiropractic management of the patient's health care needs. when indicated, the doctor of chiropractic may also co-manage, consult with, or refer to other health care providers

optometry - about the same. 65 college credit hours (a year and change), 2.5 gpa, a 4 yr program. -- then - slit lamp, snellen, better or worse, eyeglasses or contacts? see you in two years.

that's all fine. but, here's the rub. the chiropractor and optometrist - according to section 1861®(1) of the ssa,and cms sec. 410.20 -- are designated a physician with all of the privileges and honors of that professional designation.

the apn? nope. even though our scope of practice is much, much broader; our responsibility and liability - far greater. yet we are still treated as hand-maids, and put in our place as second class providers - the extenders, the mid-levels. none of us treat mid-way; perform half of a procedure; help the patient heal only half the way through a disease.

does any other primary care provider treat heart disease more or differently than you as a provider treat heart disease? does the physician carry more responsibility or liability? no. a pcp is a pcp. and god bless all of us, md, do, apn.

there is no comparison.the nurse practitioner's contribution to the health of our nation is every bit as important as the md, or do, and far above that of the dc or od. in the clinic we shoulder the responsibilities and liabilities - every one of our actions or inactions as a provider -- every moment we spend with a patient is legally ours to bear alone....

yet how many times have you been told - sorry, we need a physicians signature on that... you can't order that - it has to be ordered by a physician. we can't send that to you - we have to send it to the physician. sorry, we only credential physicians.

am i the only apn that feels a little bewildered and disgusted by this?

i have no innate yearning or desire to be called a physician mind you, its not an ego thing. but what i do have is a desire for, is to be respected for my role as a primary care provider by hospitals, insurers, labs, etc, so that i can do my job.

why i'm writing this.

as health care and our roles evolve, i believe that it is our responsibility to lobby for the advancement of our professional role, and with that updates to the ssa and cms sec. 410.20, two of the main documents that define the apn to other professionals. this is critical so that other professionals will not be confused about our role, our education, our abilities, and our responsibilities to our patients.

we regularly talk about fighting battles in my home state of tennessee, but are we only treating the symptoms of our professional legislative, political, and administrative woes? - shouldn't we also be addressing the root problems from which most of these arise - such as our absence from ssa 1861®(1)and cms sec. 410.20.

it may be time for each individual apn to write, call, or otherwise encourage other apn's as well as our advocates at ana, and our legislators to argue in favor of apn pcp's inclusion in cms sec. 410.20 and ssa 1861®(1).

because as the role of the nurse practitioner continues to evolve in response to changing societal and health care needs, so should the ssa and other government acts that define us to the nation.

social security act 1861

http://www.ssa.gov/op_home/ssact/title18/1861.htm

so. if you agree, take a moment and write someone. don't sit back and do nothing. :rotfl:change happens because of you. :) write a short note to your local chapter of ana, the national ana, george bush, your senators and your representatives and voice your desire for an updated cms sec. 410.20 and ssa 1861®(1) to help apn's across the nation do their job. thanks gang. http://www.firstgov.gov/contact/elected.shtml

respectfully,

r. martin

family nurse practitioner, chief manager and primary care provider

campbell station primary care associates

11541 kingston pike, ste 101

knoxville, tn 37922

PS. that definition at the end of my last post was not meant to be a signatory ie Primary Care Physician -- it just looks that way because of the placement in the text below my name. I won't consider myself a Primary Care Physician until the government gives me the authority to use the title "physician" - no sooner.

Tenesma,

Thanks for your post. Each of us can probably recall a personal experience where we knew more (or less) than another provider. For example I can recall asking a veteran internist how he teaches his patients to do Kegel exercises. He said that he tells them to get a suzanne summers thigh master, and that will do the trick. Just because I had to correct him, and he had 15-20 years of experience as an MD and I was a new NP, I don't feel that he is any more or less of a PCP than I am. I certainly wouldn't say that I had a greater breadth of knowledge than he did. By the same token, I'm not sure it was fair for you to say that you had a greater breadth of knowledge than those NP's -- maybe you did, but acknowledge, well... maybe you didn't. Please don't assume that because someone has MD after their name, they automatically have a greater breadth of knowledge than someone who has APRN, BC after their name. I'm sure we can agree on that.

Thanks for your post and your interest in this topic.

Rob

Primary Care Physician

Definition: Physician responsible for a person's general health care (General Practitioner, or Family Doctor).

While I haven't had a chance to respond before now, I feel that RuralNP stated it beautifully. Additionally, I've had experiences similar to that of RNMARTINNC. With all due respect to Tenesma, I've had to correct dozens of overzealous interns (with greater than three months experience) and R1s from making potentially fatal med errors within a CVICU in Memphis. Additionally, the thought of an intern with three months experience providing greater quality of care versus an NP or PA with 15 to 20 years experience is implausible at best. At worst, this thinking could prove to be very dangerous for an unsuspecting patient. Granted, the education of an M.D. vastly differs from that of an NP. Certainly no one can argue that point. Yet, the aforementioned post by RuralNP addresses this issue very well.

It seems that we all agree that the quality of care provided is the most important issue for the patient, regardless of their title. That's good to know.

NP's deserve to be called PCP's; that 's what they are, what they were trained for, what Medicare reimburses for, etc. No, they are not physicians, but as was pointed out, that term is about as meaningful as "technician" these days. Medical care as rendered from the nursing perspective is a very valuable thing. I see the NP's my ob/gyn and PCP have whenever possible for my own healthcare; let's support our own! No, an NP is not a peds neurosurgeon, but they aren't claiming to be either. We are all aware of the different training and experience that all healthcare workers have. We all have our roles in patient care; operating within your scope of practice is the name of the game.

R. Martin thanks for your recent post. You are correct in your comparision of the NP to other professions in terms of recognition and salary compensation. The nursing field orginally developed as a female dominant profession. As we know it is a sexist society and men are paid tremoundously higher for comparable work and education. Research has shown this to be true over and over. I believe our female roots is what still to this day keeps us at lower salary rate compared to other professions. It is still a sexist world, unfair, and should be stopped. The nursing profession as a whole deserves much higher pay and recognition for the education and work required to become an RN, NP, and beyond.

Ped Neurosurg and Family Practice don't have the same training. A Ped Neurosurg training is completely different from that of a primary care specialist. (ped neurosurg-7 yrs of training AFTER Med School...Primary Care 0-3 years after med school) Other than medical school, its completely different. I am fully aware of a nurse practitioners responsibilities however, they still are not Physicians. They are not their own profession. They are part of a profession.the profession of Nursing. Optometry is not a subspecialty of Ophthalmology, it is an alone sitting specialty. Ophthalmology and Optometry are two different professions. Unlike NP's which is an extention of nursing. You said that Nurse Practitioner practice similarly to Physicians and because of that, you want the privileges of a Primary Care Physician. Thats not true simply because when you say you practice similarly to a physician, you're saying that you practice similarly to a Cardiothoracic Surgeon, which is a Physician. You may practice similarly to a Medical specialist, but not a Physician. And for that, you shouldn't be given the Basic privileges of a Physican. What you're not getting is that the basic privileges of a Primary Care Physician are the same privileges of a neonatologist, cardiologist, and every other specialist. To give you that power to only practice primary care medicine would be ridiculous in every sense of the word. You are not a specialist of Medicine, you're a specialist of Nursing.

I am an RN working in an ER that utilizes the services of NPs alongside MD's. NPs are NOT working in the same scope of practice as me. They order and interpret lab work, xrays, etc. They prescribe medications. They do not start IV's or change bedpans. Their scope of practice much closer to that of MDs than RNs. They may not be MDs but it sounds like medicine to me.

Specializes in PCU, ICU, PACU.

Perhaps we should just say that all of these professionals serve a purpose. They each provide a unique kind of care for unique needs. None are more important or better than another, they just serve a different purpose. Each is is a care provider and should be recognized as such.

While I assume that your comments truly are not meant to propegate the "nurses above all others mentality", this has indeed become the result of your post. I am a new member, and frankly, shocked by the ego that pervades some of these forums. Any shrink will tell you that those who brag the most are those who have the most insecurity issues. Those who are secure in their profession and abilities don't seek out the (perceived) faults in others. You have much free time to look up inaccurate information regarding other professions.

You state that chiropractors don't have bachelor's degrees? They absolutely DO have a bachelors, and then at least four & FIVE years of graduate study before their degree is conferred. Note, I am not a chiropractor.

You also state that there is little difference between NPs and MDs/DOs. Can you be serious? The fact that they are physicians and NPs are not should be enough to clarify this misstatement. Why try to inflate our own egos with names and titles and labels? If we are insecure, we need to go to medical school and EARN the title that physicians have spent 12 + years (and hundreds of thousands of dollars) of their lives to achieve. Until we have met that challenge ourselves, we have limited room to point fingers. Even the newbie intern is still a DOC. Yes, they may have a long road to travel to reach true competency, but how proficent were you as a student nurse? Did you not have questions, make mistakes, and defer to your supervisor when you were in trouble? Did you never make a medication error in your early years? "those who live in glass houses...."

I also notice that nowhere in your list of "the enemy" do you even mention your clinician counterparts, the PAs. Nor do you refer to them as equal to NPs in any sense. You must realize that NPs and PAs function in essentially the same capacity. Except for the fact that PAs are trained similar to physicians in their model of medical education. They practice medicine, while NPs practice advanced nursing - not medicine. How can anyone who practices nursing, not medicine, have any claims to be comparable to a physician? This point can't be argued, because NPs have created their own Nursing Board to regulate their practice, claiming that doctors cannot/should not regulate nursing practice. If you want to start claiming to practice medicine, you had better start answering to your state's medical board instead. In my opinion, the creation of your state nursing boards was brilliant! What better way to refuse to be regulated by physicians then by claiming to refute the practice of medicine while embracing that of advanced nursing? It is only because of your nursing boards that NPs have any of the priviledges they enjoy today. Rx and Dx rights certainly would NEVER have been granted to you by the state medical boards, you realize.

You can't have it both ways - either you practice medicine or you practice nursing. Keep up the claim that you practice medicine and see how fast the state medical boards react....you would be wise to not s&^% where you eat!

Most jobs are even advertised for both NP/PA because they are essentially similar professions - MidLevel Practitioners, Primary Care Providers, whatever name you ascribe to them doesn't really matter. It's the care that is provided which SHOULD be the concern of all practitioners.

We would do well to join forces with those whose goals match our own. Think about joining the American College of Clinicians.

Just an end note to this, and I'm sorry in advance for any errors in posting...I'm new. there is so much hostility in this board regarding credentials. One thing I would like to address to the recent MD who posted...there are many physicians who believe that they are infinately more knowledgable than all other patient care providers. I am well aware of the training and money it takes to become a physician, as well as the dedication-my husband is a physician in specializing in Internal Medicine and who will be completing a 3 year fellowship in pulmonary/critical care. That being said, I have worked with physicians who I just do not consider(nor does my husband) to be more knowledgeable than other providers. They have a wealth of knowledge with regards to the sciences ie microbiology, biochem, etc, but are not great when it comes to assessment and diagnosis because of the lack of interpersonal skills, etc. I am not saying that mid-level providers should perform surgery. A little side note-PHYSICIANS who are not trained in surgical specialties really cannot perform surgery. The individual who posted that ridiculous comment reagrding NP vs MD is focusing on a technicality and not reality. My husband would lose his license if her performed surgery or treated a child. I do believe that NPs should receive the same reimbursement as primary care physicians for equal services. For example, if I saw a patient and treated that patient for pneumonia and my collablorating physician saw the same type of patient, we should both be reimbursed the same amount from medicare and medicaid. THAT is the real problem. We provide the same service IN THIS INSTANCE and therefore should be reimbursed the same amount. I am not an NP who feels that nurses or physician assistants should be performing surgery or high risk procedures. I also do not feel that I should handle a patient who should be referred to a specialist, such as the case with patients with pulmonary hyperstension. they have complicated medical problems and should be treated by a specialist, NOT a primary care provider, be it an NP, PA , MD or DO.

For those of you who think it's ok for a chiropracter to be called a "Dr".....those individuals did not go to medical or osteopathic schools, they do not have a PhD. Therefore, they should not use the title "Dr." Of course, this is all just my humble opinion.

Just an end note to this, and I'm sorry in advance for any errors in posting...I'm new. there is so much hostility in this board regarding credentials. One thing I would like to address to the recent MD who posted...there are many physicians who believe that they are infinately more knowledgable than all other patient care providers. I am well aware of the training and money it takes to become a physician, as well as the dedication-my husband is a physician in specializing in Internal Medicine and who will be completing a 3 year fellowship in pulmonary/critical care. That being said, I have worked with physicians who I just do not consider(nor does my husband) to be more knowledgeable than other providers. They have a wealth of knowledge with regards to the sciences ie microbiology, biochem, etc, but are not great when it comes to assessment and diagnosis because of the lack of interpersonal skills, etc. I am not saying that mid-level providers should perform surgery. A little side note-PHYSICIANS who are not trained in surgical specialties really cannot perform surgery. The individual who posted that ridiculous comment reagrding NP vs MD is focusing on a technicality and not reality. My husband would lose his license if her performed surgery or treated a child. I do believe that NPs should receive the same reimbursement as primary care physicians for equal services. For example, if I saw a patient and treated that patient for pneumonia and my collablorating physician saw the same type of patient, we should both be reimbursed the same amount from medicare and medicaid. THAT is the real problem. We provide the same service IN THIS INSTANCE and therefore should be reimbursed the same amount. I am not an NP who feels that nurses or physician assistants should be performing surgery or high risk procedures. I also do not feel that I should handle a patient who should be referred to a specialist, such as the case with patients with pulmonary hyperstension. they have complicated medical problems and should be treated by a specialist, NOT a primary care provider, be it an NP, PA , MD or DO.

For those of you who think it's ok for a chiropracter to be called a "Dr".....those individuals did not go to medical or osteopathic schools, they do not have a PhD. Therefore, they should not use the title "Dr." Of course, this is all just my humble opinion.

Ummm....... I agree with most of what you are saying, but be careful. We don't need to sensationalize things to prove a point. If your state really would pull your husband's license for treating a child, then there are serious problems. However, I doubt this is the case.

Also, many family practice programs train their residents in some obstetrical surgery and other relatively simple procedures (ie. tonsillectomy). If a physician is qualified, they are certainly allowed to operate.

This thread has been very interesting and full of many viewpoints. I am an RN with 10 years experience who is currently going back to school with the goal of MSN/FNP. I have worked in home health for the past 4 years, which is wonderful training for the role that I wish to assume once my education is complete. NP's are not MD's- nor would I want to be a MD. I prefer the nursing model of care. All disciplines bring something unique and increased knowledge in different areas for (hopefully) the benefit of the patient. For example, at my current hh position, I see tons and tons of wounds. The doctors in the area know that I am more familiar with the products and treatment of wounds than they are. They usually leave it up to us to do what we want to do with wounds. Nursing is more holisitc than medicine and they are very different in many ways. I don't know how it is in other areas- I am in the rural mountains of SE Tennessee. NP's are viewed with much esteem here. Doctors routinely work with NP's. I have a job waiting for me when I finish. Our family doctor is a great friend of mine and has been for years. She knows my background and knows that I can bring a different perspective and expertise to her practice. I will be making home visits- something I love doing and something she does not like and doesn't have time to do. NP's can have their own Medicare billing number and can also bill for care plan oversight for home health (nursing) patients. The way I see it, MD's are more likely to focus on a particular problem, and may have more knowledge about technical aspects of medicine. In contrast, NP's have been taught (thorugh the nursing model) to look at the entire patient and focus on how all things interact. To put it in very simplistic terms (and this is a broad generalization, so please don't take offense anyone), the MD tends to focus on the immediate need whereas the NP's focus is on the long haul. A good example is a patient of mine (as a HH RN) who is having chronic pain. MD put him on some extended release narcotics which has helped the pain a great deal. Yet, the MD did not even address the S/E r/t bowels for this patient. He was having quite a bit of trouble and didn't know what was wrong. I did some teaching about overall s/e, precautions to take, etc. and he is doing much better now. The MD focused on the pain only. As a NP, I would focus on lifestyle adjustments, s/e of the meds, etc. Does that make sense?

You must realize that NPs and PAs function in essentially the same capacity. Except for the fact that PAs are trained similar to physicians in their model of medical education. They practice medicine, while NPs practice advanced nursing - not medicine. How can anyone who practices nursing, not medicine, have any claims to be comparable to a physician?

So...NPs go to NP school...not medical school... and practice advanced nursing.... not medicine.

PAs go to PA school ...not medical school...and practice What???? Assisting?

When an NP and a PA order a forearm x-ray for a kid who just fell off of his bike, they both do it for the same reason....to see if anything is broken!...And so that the Doc in the main ED doesn't have to leave the bedside of the guy with the acute MI to whom he is giving thrombolytics.

We are all very smart people and, some of us, very good writers!

In my opinion, some of the energy spent on the "my daddy can beat up your daddy" dissertations should go in to more clearly defining our roles and lobbying for legislation which will, among other things, provide all mid-levels with appropriate compensation and universal acceptance for reimbursement by insurance payors.

So...NPs go to NP school...not medical school... and practice advanced nursing.... not medicine.

PAs go to PA school ...not medical school...and practice What???? Assisting?

When an NP and a PA order a forearm x-ray for a kid who just fell off of his bike, they both do it for the same reason....to see if anything is broken!...And so that the Doc in the main ED doesn't have to leave the bedside of the guy with the acute MI to whom he is giving thrombolytics.

We are all very smart people and, some of us, very good writers!

In my opinion, some of the energy spent on the "my daddy can beat up your daddy" dissertations should go in to more clearly defining our roles and lobbying for legislation which will, among other things, provide all mid-levels with appropriate compensation and universal acceptance for reimbursement by insurance payors.

Just to clarify, PA's do practice medicine. We are trained in medicine to practice medicine under the supervision of a physician.

NP's practice medicine too, it is just that they are trained in nursing. NP's practice under the supervision of a physician too, they just call it collaboration.

The job is really no different, just the type and level of training along with the politics. I have to hand it to nurses, they have some great politicians.

Pat, RN, BSN, PA-C, MPAS

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