Doctors-in-short-supply-responsibilities-for-nurses-may-expand

  1. from ny times blog prescriptions....


    [color=#808080]november 6, 2009, 9:00 am
    [color=#004276]with doctors in short supply, responsibilities for nurses may expand

    by [color=#004276]michelle andrews

    if the health care system is overhauled, patients and practitioners are likely to face a primary care bottleneck, experts say. an estimated 30 million newly insured people will begin making appointments for check-ups and other routine care with physicians who are already stretched thin caring for existing patients.

    the increase in demand may well put an end to a simmering policy dispute over the circumscribed role of nurse practitioners in medical care. if tens of millions of new patients enter the health care system, it seems clear that nurse practitioners will be needed to perform many of the tasks now performed by physicians.

    nurse practitioners are registered nurses who typically have a master’s degree in nursing. numbering roughly 125,000 nationwide, more than three-quarters of them train in primary care, making them the largest group of non-physician primary care providers, according to a study by the american college of physicians. (physician assistants, another type of non-physician provider, generally work for specialists rather than in primary care.)
    as this blog has noted, the american academy of family physicians projects a shortfall of 40,000 physician generalists — family practitioners, pediatricians, general internists and geriatricians — by 2020, even without significant changes to the current health care system. no one expects that nurse practitioners can fill that gap. the nursing profession faces its own supply challenges, with shortages of all types of nurses estimated at 260,000 over the next 15 years.

    but the health care bills moving through congress contain provisions that would increase funding for nurse training programs, including one aimed specifically at raising the number of advanced practice nurses, which include nurse practitioners....

    http://prescriptions.blogs.nytimes.c...may-expand/?em
    Last edit by NRSKarenRN on Nov 7, '09
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  2. 57 Comments

  3. by   NRSKarenRN
    from the blog...

    there are financial considerations in addition to clinical ones. nurse practitioners earn significantly less than primary care physicians and can provide comparable care at a lower cost. a rand corporation study that examined ways to control health care spending in massachusetts found that increasing the use of nurse practitioners and physician assistants for certain types of office visits could save up to $8.4 billion by 2020.
    federal funding for nurse education has always been a sore spot among nurses. unlike doctors in training, whose residencies are almost entirely funded by medicare, most nursing education is self-financed. nurse education received a little over $300 million in federal funding in 2006. half of that amount was restricted to hospital diploma programs, which graduate only about 5 percent of nurses today.

    the senate finance committee bill would provide $50 million annually from 2012 through 2015 to fund a medicare demonstration program for graduate nurse education. participating hospitals would receive medicare reimbursement for their education and clinical instruction costs. meanwhile, the house health reform bill that was unveiled last week would authorize an additional $638 million to support nurse training from 2011 to 2015, including training for advanced practice nurses.

    "this bill recognizes that we need more resources for graduate nursing education," said brenda cleary, director of the center to champion nursing in america a program of the aarp public policy institute.
    nursings is finally being recongnized now for the tremendous impact we can have on patient care at all levels. time for the "1 in 44 voters = nurse" to speak up to their congressional representatives:

    u.s. senators - search for your senators by name, state, or congressional class; and visit their websites.

    u.s. representatives - find contact information for your u.s. representative by typing in your zip code.
  4. by   Isabel-ANP-BC
    I'm an ANP student training to do primary care of adults. I find it rather short sighted to be called a mid level provider who requires a collaborating physician (NYS requires a collaborating physician) do what I'm being trained to do. Studies show that NPs provide care that is holistically better than many physicians and which provide outcomes which are many times better than a physician in areas such as primary care, preventative care, diabetic care, and so on. I don't expect to do surgery, but I would like to be recognized for what I am going to be capable of doing and how well I will be able to do it.
  5. by   HeartsOpenWide
    In my opinion doctors should be reserved for specialized care/high risk cases. NPs should do 90% of the work. Health care would be a whole lot more affordable...if CNMs can save the US $8.5 billion/year by utilizing 75% of the patients, imagine what savings would come of utilizing NPs for all areas of heath care.
  6. by   eriksoln
    Oh great. We already have to carry the CNAs, dietary, all the other departments (radiology, lab, PT/OT).

    Now we have to put docs on our backs too? lol
  7. by   Abby Normal
    Yes, NRSKarenRN, those exact paragraphs leapt out at me when I read that story online.

    This is important to me, as I'm a not-young student about to take on a mountain of debt, on top of a mortgage, for education to fill a couple of what I keep hearing are the most critically needed areas within nursing. Too bad there's very little money out there for my chosen areas right now at the master's level.

    My motives are pure (or, you know, as pure as human motives get). I'm definitely not going into this field for the money. But I'd at least like to break even before I die.

    I hope this will help. If the screaming ever stops ...
  8. by   Teresag_CNS
    Nurse education received a little over $300 million in federal funding in 2006. Half of that amount was restricted to hospital diploma programs, which graduate only about 5 percent of nurses today.
    Diploma programs? Huh? Why on earth were they singled out for $150 million when they are disappearing?
  9. by   dgenthusiast
    Quote from Izzy_RN_BSN
    I'm an ANP student training to do primary care of adults. I find it rather short sighted to be called a mid level provider who requires a collaborating physician (NYS requires a collaborating physician) do what I'm being trained to do. Studies show that NPs provide care that is holistically better than many physicians and which provide outcomes which are many times better than a physician in areas such as primary care, preventative care, diabetic care, and so on. I don't expect to do surgery, but I would like to be recognized for what I am going to be capable of doing and how well I will be able to do it.
    Actually, I have not come across any valid studies (ie. ones not significantly flawed) that show this at all. Please provide citations. Pretty much every single study so far comparing NPs and physicians has either had huge flaws (for example, looking at completely useless values such as diastolic pressure) which provide perfect examples of how a study should not be done or they have been led by people such as Mundinger, who is notoriously very anti-physician and thus, there's a lot of bias involved in those studies. Like I said, please provide citations of a well-designed study that shows that NPs provide better care than physicians. Also, please note that patient satisfaction does not mean that the medical care provided was adequate or better than that of physicians.
  10. by   dgenthusiast
    Quote from HeartsOpenWide
    In my opinion doctors should be reserved for specialized care/high risk cases. NPs should do 90% of the work. Health care would be a whole lot more affordable...if CNMs can save the US $8.5 billion/year by utilizing 75% of the patients, imagine what savings would come of utilizing NPs for all areas of heath care.
    The problem with this is how do you know when a patient needs specialized care or that they symptoms you're looking at are not due to something more sinister than a common occurance? You can't deny that NP/DNP training is significantly less compared to that of physicians. So how would you know what to look for and refer patients to specialists? Yea it's true that the majority of cases walking in could be taken care of by a high school student following algorithms; the distinction between physicians and midlevels is the physicians' ability to distinguish between something routine and something worse. A routine patient visit could easily take a turn for the worse if the underlying condition is not caught in time.
  11. by   Teresag_CNS
    Quote from dgenthusiast
    The problem with this is how do you know when a patient needs specialized care or that they symptoms you're looking at are not due to something more sinister than a common occurance? You can't deny that NP/DNP training is significantly less compared to that of physicians. So how would you know what to look for and refer patients to specialists? Yea it's true that the majority of cases walking in could be taken care of by a high school student following algorithms; the distinction between physicians and midlevels is the physicians' ability to distinguish between something routine and something worse. A routine patient visit could easily take a turn for the worse if the underlying condition is not caught in time.
    I disagree. APNs refer patients readily if there is doubt that their condition may require specialist consultation. I recall reading studies indicating that NPs refer more readily than physicians. The idea that an NP might "miss something" is flawed because the history and physical exam plus maybe a few labs that the primary care provider has to make their decisions do not contain "hidden" hints about serious illness. Interpreting this information is mastered pretty quickly by health care professionals with post-graduate study, whether nurse or physician. In fact, the whole system of medical training (which is part of what NPs get) is geared toward detecting serious illness so it can be ruled out first. There is absolutely no evidence that health problems are missed by NPs, and there is plenty of evidence that APNs of all stripes provide safe and effective care.

    As far as education, whether APNs get less education than physicians or not is a matter of perspective. Most nurses who enter graduate school do so after spending some time in clinical practice, unlike physicians. The master's degree APN has more credits than the vast majority of master's degree graduates in other fields. When the DNP becomes the standard for APNs, years of education between nurses and physicians will dwindle even further, making residency and fellowship the main difference. DNPs will not have as many hours of residency as physicians, because our profession does not have the money to make that happen. Most nurses pay their own way, while physicians doing residencies are paid through federal programs that are quite lucrative for the hospitals that employ them. However, the lack of residency hours is made up at least in part by the fact that most APNs are already experienced nurses when they begin graduate school.
  12. by   GilaRRT
    Why would you not want to collaborate with a physician? I had a moment of clarity in Afghanistan while performing independent medical duties. I had several people present with different types of skin lesions and assorted complaints. I was reduced to playing wheres Waldo in a dermatology text in multiple unsuccessful attempts to identify and treat their problems.

    I am not sure a couple of years of classes and 700 or so hours of clinical experience would have prepared me to deal with the said situation. If this is the case, I could not see independently managing people with a plethora of problems spanning the entire range of ages. As an APN, I would be more than happy to work with a physician. IMHO.
  13. by   mige
    Quote from Teresag_CNS
    I disagree. APNs refer patients readily if there is doubt that their condition may require specialist consultation. I recall reading studies indicating that NPs refer more readily than physicians. The idea that an NP might "miss something" is flawed because the history and physical exam plus maybe a few labs that the primary care provider has to make their decisions do not contain "hidden" hints about serious illness. Interpreting this information is mastered pretty quickly by health care professionals with post-graduate study, whether nurse or physician. In fact, the whole system of medical training (which is part of what NPs get) is geared toward detecting serious illness so it can be ruled out first. There is absolutely no evidence that health problems are missed by NPs, and there is plenty of evidence that APNs of all stripes provide safe and effective care.

    As far as education, whether APNs get less education than physicians or not is a matter of perspective. Most nurses who enter graduate school do so after spending some time in clinical practice, unlike physicians. The master's degree APN has more credits than the vast majority of master's degree graduates in other fields. When the DNP becomes the standard for APNs, years of education between nurses and physicians will dwindle even further, making residency and fellowship the main difference. DNPs will not have as many hours of residency as physicians, because our profession does not have the money to make that happen. Most nurses pay their own way, while physicians doing residencies are paid through federal programs that are quite lucrative for the hospitals that employ them. However, the lack of residency hours is made up at least in part by the fact that most APNs are already experienced nurses when they begin graduate school.
    Can you please provide the study that you mentioned above? Can you please provide a specific percentage of nurses that have experience when they begin graduate school?

    I will provide the medical side of view:

    Med student 1st and 2nd years in class from 8-5 every day.
    3rd and 4th years in the hospital/clinics 5-6 days per week from 8-5 and staying until 12AM when on call with residents and in some places overnight.

    Resident for IM spends 70 hours per week in average at the hospital which translates to 3640 hours per year so at the end of a 3 year residency they have 10920 hours of experience if the avg is 70 hours. This 10920 (give or take since we have 3 weeks of vacation so thats 210 less hours) hours doesnt take into account the hours that resident spend at home/library preparing for the Step 3 (weeks-1 month of preparation) and ABIM (4-5 months of preparation) and reading after their duties in the hospital.

    The nurses at the hospital where I work have 12 hours shift 4 times per week= 48 hours per week. Therefore in a year nurses work 2496 hours (if no overtime) and in those 3 years that a resident works its 7488.

    10700 vs 7488, and lets not forget one is directed entirely at medicine and the other at nursing (therefore no pathology/treatment training 100% of the time).

    In terms of pathology/treatment training you cannot compare one to the other, they are different schools with very different training objectives in mind. And again this is not to flame, is just to ilustrate that physicians and nurses have different roles in the healthcare system and they were trained for a specific objective.
  14. by   dgenthusiast
    Quote from Teresag_CNS
    I disagree. APNs refer patients readily if there is doubt that their condition may require specialist consultation. I recall reading studies indicating that NPs refer more readily than physicians. The idea that an NP might "miss something" is flawed because the history and physical exam plus maybe a few labs that the primary care provider has to make their decisions do not contain "hidden" hints about serious illness. Interpreting this information is mastered pretty quickly by health care professionals with post-graduate study, whether nurse or physician. In fact, the whole system of medical training (which is part of what NPs get) is geared toward detecting serious illness so it can be ruled out first. There is absolutely no evidence that health problems are missed by NPs, and there is plenty of evidence that APNs of all stripes provide safe and effective care.

    As far as education, whether APNs get less education than physicians or not is a matter of perspective. Most nurses who enter graduate school do so after spending some time in clinical practice, unlike physicians. The master's degree APN has more credits than the vast majority of master's degree graduates in other fields. When the DNP becomes the standard for APNs, years of education between nurses and physicians will dwindle even further, making residency and fellowship the main difference. DNPs will not have as many hours of residency as physicians, because our profession does not have the money to make that happen. Most nurses pay their own way, while physicians doing residencies are paid through federal programs that are quite lucrative for the hospitals that employ them. However, the lack of residency hours is made up at least in part by the fact that most APNs are already experienced nurses when they begin graduate school.
    I respectfully disagree. The idea that a midlevel might miss something a physician might catch is a perfectly valid argument. The amount of pathophys/path training that an NP/DNP receives is considerably less that what a physician receives. This can definitely translate to NPs/DNPs missing something, primarily because they've never learnt about it or they've never learnt about it to the extent that the physician has.

    I also disagree that whether midlevels get less education than physicians is a matter of perspective. It's a fact that they get less training than physicians. It's nigh impossible to cram 7+ years of physician training (4 years of med school + a minimum of 3 years of residency) into half that time. Also, physicians receive greater than 15000 clinical hours of medical training during M3/M4 and residency compared to less than 1000 that most NP/DNP programs require. Not only that, the basic science foundation of physicians is significantly greater than that of NPs/DNPs, whose curricula contains a significant amount of nurse activism and other courses that aren't very useful clinically.

    While prior experience as a nurse might help in the transition to NP/DNP, it is not a replacement for medical training. Unless you're suggesting you practiced medicine as a nurse? There's a significant difference between thinking in a medical manner and thinking in a nursing model, as many nurses themselves are very quick to point out. So, that prior clinical experience you have as a nurse does not compensate for the less than 1000 clinical hours of medical training that NP/DNP programs require. Also, there are several direct-entry programs where you can earn an NP or DNP without any prior healthcare experience at all. That's pretty scary!

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