Doctor Shortage-Who Should Fill the Gap?

Not flaming or ranting-just stating facts based on the question that I read.

Again, I believe the savings portion touted has always been on a greater number of available primary spots=better primary care=less overall cost.

Not specific to NPs, PAs or MDs...just access to care can make all the difference.

MDs have abandoned basic care...someone must fill it...why not NPs?

While I'd love to do basic research for you right now....I can't as I am in the middle of several projects....HOWEVER, my comments have been primarily as an overall response. I have many concerns about proper programs, clinical hours and the types of nurses who will become NPs. I work with a variety of NPs, PAs and physicians in the ER-my scope of practice and our practices in the ER are very different from other types of nurses. I can only base my opinions on my type of nursing and think that any decent critical care RN would make an excellent candidate for Advance Practice Nursing.

I don't know any nurse that wants to be a physician, however I can tell you I am tired of the multiple strokes I see in the African American community due to lack of access, lack of medicine, lack of education and minimal time spent with these patients. As this has become my focus due to (20+) patients in my direct care who suffered a stroke 40-50s and the reason I want to provide adult primary care. Prevention is everything! These people may recover from their neuro deficits or not, but they and their families will never be the same! It has impacted my school work, my educational focus, and my feelings about US Healthcare. While this has been hard hitting (to my feelings about healthcare disparities) there are so many others that would benefit from the approach the nursing model makes at patient health.

As for the Canadian numbers-I'll be happy to email one of my politically active professors who has this info at her fingertips-as for Americans self-reporting-my pre-mentioned strokes all self reported good health before their strokes-they used to have hi bp and diabetes..hmmmm. Americans aren't given the true facts-only a pill to fix it all! Also, our fantastic system cuts loosed our mentally ill and makes it near impossible to treat depression or any other mental illness in those 5-20 visits allotted. In Canada, depression and other mental health issues are managed by primary care.

When was the last time your doctor sat down and spoke to you? I have one for the first time in 15 years who does, but he's young....I expect it won't last long.

As for the most comprehensive exam I every received-it came from an NP at my college. I couldn't believe it! The first time I'd ever seen someone actually do what they are supposed to do! Isn't that sad?

I work with a great healthcare team and want to continue to be part of a TEAM. No woman or man is an island, no one knows it all, no one is perfect, everyone is referred at one time or the other to a specialist-as it should be.

M

The problem is that physician income makes up a relatively small percentage of healthcare costs (I don't have an article right off the top of my head but I seem to remember it being around 7-10% after taking into account overhead costs). So even if physician pay was reduced to zero, there wouldn't be a significant effect on healthcare expenditures. If you want to be cost efficient, you need to look at other areas such as end of life care, tort reform, defensive medicine, the ridiculous amount of administrators, etc. before looking at something like physician pay, which will have a minimal impact on expenditures.

NPs/DNPs will not really save any money, in my opinion. The most vocal group of NPs/DNPs is actively pushing for equivalence to physicians and equal reimbursement as physicians. Not only that, with a lower level of training compared to physicians, it's not too big of a stretch to think that NPs/DNPs will be referring to specialists more than PCPs would. So, I can't really see people arguing that NPs/DNPs will save any meaningful amount of money. And as I've argued in a different thread, I firmly believe that the level of training NPs/DNPs receive is not adequate to practice without any physician supervision. This is especially true considering that there are several direct-entry NP programs where you need no prior healthcare experience at all and can get an NP within a few years.

You guys argue a lot that patient care is the most important thing. If this is true, you really should do something about the inadequate training that NPs/DNPs receive or you should not let them practice independently. Saying that you, unlike doctors, care about the patient and then saying that people with less training than physicians should practice independently is pretty hypocritical.

Heh first off I'm a PA, so I appreciate your argument but I am not really in the place to defend the DNP reimbursement issue. That's their deal! (Although I see it as self defeating as well.)

Re: independent practice, I have to agree (with qualification) to my ~colleague Mike Jones, PA-C who psoted comment on the CNN article recently: PAs with a documented history of experience and quality measures should have a route to independent practice in primary care. A lot of wrinkles to iron out, but I see it as a safe and viable option. I don't see the same logic or need in most specialty care.

Re: cost, I agree (and have argued on the PA forum) with most of the above. The numbers from the CBO about tort reform put the total cost in the 7% range as well, BTW, about as much as you cite for physician salary. I would remind you that the high incentives for procedural over cognitive services weigh care in favor of the inpatient arena, which ties into it facility and materials costs- a healthy addition to physicians professional fees (often, way more!)....so unloading that end of the care spectrum probably has more savings.

Eliminating private insurance costs is the major key to our decline in overall health and prohibitive increases in care consumer cost.

Also, I certainly haven't argued that "a lot that patient care is the most important thing"; often the contrary is true......

MDs have abandoned basic care? Really? Are you one of those people who believes that only nurses care about the patient while doctors only care about the disease?

You seem to suggest that any medical care is better than no care. If that's true, why can't I go to a remote, rural part of the country and practice medicine? After all, it's better than nothing right? Plus, I have a pretty strong basic science foundation already; I just need to learn to apply it clinically.

You cannot say NPs/DNPs/PAs should be allowed to practice independently and then disagree that 4th year med students shouldn't. Think about it. 4th year med students would have a stronger basic science foundation that NPs/DNPs; you can't argue otherwise. And 4th year med students also gain around 3-4000 hours of clinical training thinking in a medical manner during their M3 year.

You can't say all those years you spent as a nurse = practicing medicine/thinking like a physician. While I have no doubt that a significant amount of years spent as a nurse will help the transition from nursing to practicing medicine, it's kinda misleading to say that all those clinical hours as a nurse make up for the lack of clinical hours practicing medicine in the NP/DNP curriculum.

If anything, PAs have more of a right to practice independently than NPs/DNPs. At least their training is somewhat standardized, they're regulated by the BOM, and their training is much more similar to physician training than any NP/DNP curricula that I've come across.

-HOWEVER, the NPs I work with are not only capable but they function efficiently and independently-in either case I would use either for treatment.

dg not sure what your issues are-what type of healthcare professional are you? Are you a resident, have you had bad experiences with mean nurses, or do you just not believe nurses are able to offer quality care at a higher level?

As for MDs abandoning basic care...where are all the primary care physicians? We are facing a severe shortage of PMDs, who would you suggest fill the gap? Schools are not filling with PMD candidates because the compensation they say they require isn't there!

As for residents I work with plenty of them and have seen things that make my hair stand on end! Them and all their clinical hours! Funny I see a person when I care for a person, the most common thing I see in my teaching hospital is opportunities for disease process and PRACTICE! This goes for any healthcare student or new grad! Today's example: ICU resident (senior today) give Digoxin for that SVT, me-did you look at the labs? Dirty look ensues along with exasperated sigh....too bad Dig level 2.1, how about adenosine says I....oh no says he. Cardiology comes 10 minutes later-6mg adenosine=sinus rhythm; no longer a CCU patient. Three hours of SVT and a single point of view(prior to my shift)-please don't tell me about residents and qualifications. I've seen too much!

Not to say many aren't wonderful because they are!

As for PA's; I work with a great bunch of them-admire their skill, love working with them-HOWEVER, the NPs I work with are not only capable but they function efficiently and independently(all were Paramedics, in the military, and nurses)-in either case I would use either for treatment.

Of course this is only my experience and my opinion....but that's what makes us all unique in our viewpoints.

What you keep missing in all of my posts is I keep saying team, team, team, TEAM! Filling in the gap, obviously our definitions couldn't be more different about what is important for our citizens to be healthy. Preventive care, education, maitenance, follow up, CONTACT and RELATIONSHIP.

Oh BTW I agree and have already noted in several posts that I am also concerned about the amount of clinical time in NP programs-I have been just about beaten up by our Dean to join an Emergency NP program for which I don't feel that I or any other new NP would be appropriate for....It may be something I look at after a few years of working as an NP, but not something I think any new NP should be looking at. One must build upon the knowledge they have before leaping in to practice at such a level.


M

I explained in a previous post why medical students are avoiding primary care. It's because it doesn't pay well and when you have a massive debt on your back, do you want to go into the lowest paying specialty and spend more years repaying loans or would you go into a higher paying specialty? As I mentioned, PCP reimbursement needs to increase or there needs to be some sort of loan forgiveness, etc. that would provide an incentive for medical students to look at primary care.

Regarding your anecdotal evidence on the performance of residents and NPs, unfortunately, it's just anecdotal. If I say that I've only had great experiences with doctors and PAs, who's more right? You or me? There needs to be some sort of valid outcomes study done. None of the studies out there right now are without flaws that discredit them. If we do go by what you said and residents, with all their years of clinical training made some "hair-raising" mistakes, imagine how much worse the mistakes would be from a lesser trained midlevel.

As for your statement that doctors only care about the disease and not the patient, I'm sorry but I'm going to have to call BS on that one. Can you provide proper evidence of that beyond anecdotes?

And you haven't answered my question as to why 4th year med students can't practice independently when they've already had better basic science education and more clinical hours than graduating NPs/DNPs.

And I agree with you that healthcare should be team based. However, it's hard to get along with everyone when one group claims their lower level of training is equivalent to that of physicians (and that they should be allowed to practice independently because of that). As I mentioned in a previous post, I'm not trying to be inflammatory or rude. I just don't understand this push for allowing people with significantly less training than physicians to practice medicine independently.