Full Practice Authority

[rkealy]

I am not sure on what side of the fence I stand on as of yet. I am having difficulty squaring the different level of standards for an APN to practice medicine vs a physician. Can somebody explain this to me?

[popopopo]

4 hours ago, Pachinko said:

Very true. And yet, multiple studies show that NPs provide quality primary care. Why is that? It’s an interesting question.

I used to work bedside in a unit with lots of NPs. In that setting, roles were sharply demarcated, with MDs directing the care and NPs doing so-called “scut work” like writing routine prescriptions and simpler procedures. I would not want to be under the care of an NP in a cardiac unit. But a primary care office is not a cardiac unit. Perhaps MDs are working below their potential in the primary care role?

The system itself may be to blame. MDs who choose a primary care track go through lots of training, including rotations in the hospital and learning surgeries. But in primary care, where you have to see a new patient every 15 minutes, how can they utilize that knowledge? I think that is why, at least in my experience, primary care NPs and MDs provide almost identical care. We all work under the same constraints, with the same goals, and we all refer on to specialists at about the same point.

Add to this that education can take you only so far. For most people, a few years in the field whittles your knowledge base down to the specifics of your population. An MD may have more schooling, but much of that recedes with time and experience. We are all left with the same patients and the same standards.

I have big concerns about low standards for NP schools at present, but I don’t think that’s something that we can depend on physicians to correct. If oversight needs to happen, I don’t see why another NP with a certain amount of experience can’t be the one to oversee new grads and pick out the ones that are incompetent. In any event, I think that NPs should have the option of becoming independent after a certain number of years of practice without incident.

Very good point. MD/DO should be able to go primary care straight out of medical school. All that extra training in residency is probably going to waste in primary care, since the outcome we have with them are the same.

[TuxnadoDO]

On 10/1/2019 at 8:10 PM, popopopo said:

Very good point. MD/DO should be able to go primary care straight out of medical school. All that extra training in residency is probably going to waste in primary care, since the outcome we have with them are the same.

Do you believe that your info on NP outcomes is based on reliable data from well-structured studies on independent NPs?

And trust me, new medical school grads are not prepared to practice medicine independently.

[FullGlass, BSN, MSN, NP]

18 hours ago, TuxnadoDO said:

Do you believe that your info on NP outcomes is based on reliable data from well-structured studies on independent NPs?

And trust me, new medical school grads are not prepared to practice medicine independently.

Thank you for participating here. There are have been over 100 studies comparing MD care to NP care in the primary care setting. ALL of them found that NPs provide the same quality of care and their patient satisfaction is higher in general than MDs. This debate has gone way beyond "proving" this point. I have yet to see an MD or DO provide one single study to the contrary. In addition, NPs have had FPA in many states and in the Veterans Administration for some time and there is not one single shred of evidence that quality of care has declined in such jurisdictions. If it had, we'd know it by now.

Personally, given the shortage of primary care providers, and the escalating costs of medical school and higher education in general, the US should consider the European model for med education: 3 years undergrad, then 3 years med school. That would be an enormous savings to students. I also think med schools should offer a fast track program for people who know they want to be primary care MDs so they don't spend time on irrelevant areas.

Personally, I support NP residency for 1 year, but the problem is who is going to pay for it?

Right now, in states with restricted practice, there really is no NP oversight and it is just a way to line doctors' pockets and it really hurts communities in areas with shortages of providers.

In reality, I think we need to move away from having MDs in primary care. Just have a few for complex cases and have mid-levels handle the rest. I bet that is what will happen in the long run.

[TuxnadoDO]

3 hours ago, FullGlass said:

Thank you for participating here. There are have been over 100 studies comparing MD care to NP care in the primary care setting. ALL of them found that NPs provide the same quality of care and their patient satisfaction is higher in general than MDs. This debate has gone way beyond "proving" this point. I have yet to see an MD or DO provide one single study to the contrary. In addition, NPs have had FPA in many states and in the Veterans Administration for some time and there is not one single shred of evidence that quality of care has declined in such jurisdictions. If it had, we'd know it by now.

Personally, given the shortage of primary care providers, and the escalating costs of medical school and higher education in general, the US should consider the European model for med education: 3 years undergrad, then 3 years med school. That would be an enormous savings to students. I also think med schools should offer a fast track program for people who know they want to be primary care MDs so they don't spend time on irrelevant areas.

Personally, I support NP residency for 1 year, but the problem is who is going to pay for it?

Right now, in states with restricted practice, there really is no NP oversight and it is just a way to line doctors' pockets and it really hurts communities in areas with shortages of providers.

In reality, I think we need to move away from having MDs in primary care. Just have a few for complex cases and have mid-levels handle the rest. I bet that is what will happen in the long run.

I have read several of those studies. Other than study design issues, the main problem I have with them is the outcome timeline. If chronic issues are managed with more or less skill, are you really going to see a difference in outcome after two years of follow up? They are flawed from the get-go. DM and HTN are slow killers. Further, Primary care physicians are the first line of defense when new symptoms present. Primary care is not easy. It isn’t just following a flow chart of guidelines. The new NPs coming from diploma mills have not been trained in the wide breadth and depth of medicine required to put the puzzle pieces together. I am not putting down NPs or NP training - there’s only so much you can learn in that time period and I imagine most do their very best and learn a lot. But imagine being in medical school for four years and then residency for 3+ years, a completely grueling, immersive and intensive experience which occupies your whole life, and then an RN who attended an 18 month online NP program and had to scrape together his or her own shadowing “Clinicals” turns around and says they can do your job just as well. I am describing my own friend’s experience in NP school, by the way. NP groups and boards are full of new NPs asking very basic questions about initial work up and management with incomplete info provided. With many years of experience, I have no doubt that some NPs could provide the same level of care with managing DM and HTN within established guidelines, but that isn’t all there is to being a primary care physician.

Physicians have never really felt the need to justify their years of training by publishing long-term well-structured studies to prove they practice medicine more skillfully than NPs and PAs. But now with everything going on regarding independent practice, I wouldn’t be surprised to see these after some time.

Again, I’m not insulting NPs. If I had a private practice I would certainly welcome a well trained NP. And there are even some physicians who would agree with what you’re saying. After everything I’ve been though, medicine is the most humbling science and amazing art, and I still have more to learn. The more you know, the more you realize you don’t know.

[FullGlass, BSN, MSN, NP]

54 minutes ago, TuxnadoDO said:

I have read several of those studies. Other than study design issues, the main problem I have with them is the outcome timeline. If chronic issues are managed with more or less skill, are you really going to see a difference in outcome after two years of follow up? They are flawed from the get-go. DM and HTN are slow killers. Further, Primary care physicians are the first line of defense when new symptoms present. Primary care is not easy. It isn’t just following a flow chart of guidelines. The new NPs coming from diploma mills have not been trained in the wide breadth and depth of medicine required to put the puzzle pieces together. I am not putting down NPs or NP training - there’s only so much you can learn in that time period and I imagine most do their very best and learn a lot. But imagine being in medical school for four years and then residency for 3+ years, a completely grueling, immersive and intensive experience which occupies your whole life, and then an RN who attended an 18 month online NP program and had to scrape together his or her own shadowing “Clinicals” turns around and says they can do your job just as well. I am describing my own friend’s experience in NP school, by the way. NP groups and boards are full of new NPs asking very basic questions about initial work up and management with incomplete info provided. With many years of experience, I have no doubt that some NPs could provide the same level of care with managing DM and HTN within established guidelines, but that isn’t all there is to being a primary care physician.

Physicians have never really felt the need to justify their years of training by publishing long-term well-structured studies to prove they practice medicine more skillfully than NPs and PAs. But now with everything going on regarding independent practice, I wouldn’t be surprised to see these after some time.

Again, I’m not insulting NPs. If I had a private practice I would certainly welcome a well trained NP. And there are even some physicians who would agree with what you’re saying. After everything I’ve been though, medicine is the most humbling science and amazing art, and I still have more to learn. The more you know, the more you realize you don’t know.

I don't understand your point. You have read a few of those studies and found flaws. Wow. Sorry, I'm not impressed. There aren't a lot of perfect studies out there. Since you are the one who brought this up, please provide some of your own evidence. It isn't the job of NPs to defend ourselves. Have you read every single study on NP care quality? Do that, then get back to us. And you conveniently ignore that no jurisdiction with FPA has reported quality issues.

Please tell me what makes an NP unable to manage HTN and diabetes and other chronic issues. What magic does an MD perform? Are NPs somehow unable to read, understand, and practice according to guidelines? I'm sick and tired of the attitude of some that MDs are somehow gods. Well, they are not. They vary in quality. I'd rather see a good NP than a crappy MD for my care, and I've seen plenty of crappy MDs.

Here are some examples:

- Pt with neurological problems sees me for first time after moving to my area. I do H&P, including a neuro exam. Pt and her husband are thrilled - her previous MD never did a neuro exam! She knew this because when she was in the hospital they gave her the neuro exam, but her PC MD never did.

- Pt with obvious ear infection, with ear full of pus and in agonizing pain is diagnosed by MD as having anger issues and referred to mental health.

- Another new pt comes to see me. She has diabetes and I start her on diabetes mgt. She is surprised and says her previous MD never did anything about it and her A1C1 was over 10!!! I get her previous medical records and she was right - previous MD never did anything to manage her diabetes.

- Pt with out of control diabetes comes in. She refuses to take care of herself. I catch a kidney issue that comes close to killing her - one more day and she could have been dead. She continues to see me after recovering and tells me I'm the first provider in a long time that she trusts and can talk to. In other words, she wouldn't cooperate with the MDs she had seen.

- Pt comes in looking sick. I have seen her before, and I know in my gut something is not right. She had starting seeing an MD in our clinic and saw him yesterday, c/o of feeling sick and abdominal issues. The MD dismissed her complaint. Now she is back with her husband and requested me. I asked for urine sample and when patient is in bathroom, husband tells me he has very bad feeling and asks if he should take wife to ER. I look at him and say I also have bad feeling, he knows his wife, and he should trust his gut. Husband takes wife to ER. I tell the MD this, just to keep him informed and his first response is anger at me for undermining him, not one word of concern about patient. Then he rants about how the patient is cuckoo and probably nothing is wrong with her. I was horrified. The next day, I call the patient to check on her. She has been admitted to hospital because the ER couldn't figure out what was wrong with her, but she was going into sepsis. A couple days later I call her again and she is still in hospital. Long story short, she was in the hospital for almost 3 weeks, turns out she had retropharyngeal abscess. She stopped seeing the MD and began seeing me again. Oh, and I had less than one year of experience and the MD had about 30.

Do I need to go on? If you have an issue with FPA, then build your own case. Don't expect others to do it for you and don't expect us to defend NPs to you.

I have enormous respect for most docs and have been fortunate to have some wonderful mentors. Those docs also respect and appreciate good NPs.

[guest478081]

They are all crap studies and almost all of them are done by nursing organizations and are biased for that reason.

Why would the docs need to do studies showing they are superior? Then no patients would want to see midlevels employed by physicians and it would hurt business. Double edged sword.

Not a day goes by on this forum that fullglass doesn’t come on here prancing around like queen of the nursing universe saying how he or she out smarted xyz physicisn that day

NP education sucks and we all know it. Some are still good but to deny this is an out right lie.

Also why so salty the DO on this forum is pretty considerate even though every time he responds some salty midlevel wanna be Doctor lashes back at him instead of trying to provide a good conversation

NP needs to tighten up their education like CRNA have before they actually think they know anything

hate to say it fellow nurses but we aren’t doctors. I’m not an anesthesiologist nor will I try to fake news be one like the AANA wants us to be. Same to aanp and aanc

worst thing about nursing are nurses. Barf. Know your place

[guest478081]

1 hour ago, FullGlass said:

I don't understand your point. You have read a few of those studies and found flaws. Wow. Sorry, I'm not impressed. There aren't a lot of perfect studies out there. Since you are the one who brought this up, please provide some of your own evidence. It isn't the job of NPs to defend ourselves. Have you read every single study on NP care quality? Do that, then get back to us. And you conveniently ignore that no jurisdiction with FPA has reported quality issues.

Please tell me what makes an NP unable to manage HTN and diabetes and other chronic issues. What magic does an MD perform? Are NPs somehow unable to read, understand, and practice according to guidelines? I'm sick and tired of the attitude of some that MDs are somehow gods. Well, they are not. They vary in quality. I'd rather see a good NP than a crappy MD for my care, and I've seen plenty of crappy MDs.

Here are some examples:

- Pt with neurological problems sees me for first time after moving to my area. I do H&P, including a neuro exam. Pt and her husband are thrilled - her previous MD never did a neuro exam! She knew this because when she was in the hospital they gave her the neuro exam, but her PC MD never did.

- Pt with obvious ear infection, with ear full of pus and in agonizing pain is diagnosed by MD as having anger issues and referred to mental health.

- Another new pt comes to see me. She has diabetes and I start her on diabetes mgt. She is surprised and says her previous MD never did anything about it and her A1C1 was over 10!!! I get her previous medical records and she was right - previous MD never did anything to manage her diabetes.

- Pt with out of control diabetes comes in. She refuses to take care of herself. I catch a kidney issue that comes close to killing her - one more day and she could have been dead. She continues to see me after recovering and tells me I'm the first provider in a long time that she trusts and can talk to. In other words, she wouldn't cooperate with the MDs she had seen.

- Pt comes in looking sick. I have seen her before, and I know in my gut something is not right. She had starting seeing an MD in our clinic and saw him yesterday, c/o of feeling sick and abdominal issues. The MD dismissed her complaint. Now she is back with her husband and requested me. I asked for urine sample and when patient is in bathroom, husband tells me he has very bad feeling and asks if he should take wife to ER. I look at him and say I also have bad feeling, he knows his wife, and he should trust his gut. Husband takes wife to ER. I tell the MD this, just to keep him informed and his first response is anger at me for undermining him, not one word of concern about patient. Then he rants about how the patient is cuckoo and probably nothing is wrong with her. I was horrified. The next day, I call the patient to check on her. She has been admitted to hospital because the ER couldn't figure out what was wrong with her, but she was going into sepsis. A couple days later I call her again and she is still in hospital. Long story short, she was in the hospital for almost 3 weeks, turns out she had retropharyngeal abscess. She stopped seeing the MD and began seeing me again. Oh, and I had less than one year of experience and the MD had about 30.

Do I need to go on? If you have an issue with FPA, then build your own case. Don't expect others to do it for you and don't expect us to defend NPs to you.

I have enormous respect for most docs and have been fortunate to have some wonderful mentors. Those docs also respect and appreciate good NPs.

Let me guess you pick up all the minute adrenal nodules missed by those fools called radiologists too with your hot tail anatomy knowledge you got from BIO101

laff

[traumaRUs, MSN, APRN]

8 minutes ago, kudzui said:

They are all crap studies and almost all of them are done by nursing organizations and are biased for that reason.

Why would the docs need to do studies showing they are superior? Then no patients would want to see midlevels employed by physicians and it would hurt business. Double edged sword.

Not a day goes by on this forum that fullglass doesn’t come on here prancing around like queen of the nursing universe saying how he or she out smarted xyz physicisn that day

NP education sucks and we all know it. Some are still good but to deny this is an out right lie.

Also why so salty the DO on this forum is pretty considerate even though every time he responds some salty midlevel wanna be Doctor lashes back at him instead of trying to provide a good conversation

NP needs to tighten up their education like CRNA have before they actually think they know anything

hate to say it fellow nurses but we aren’t doctors. I’m not an anesthesiologist nor will I try to fake news be one like the AANA wants us to be. Same to aanp and aanc

worst thing about nursing are nurses. Barf. Know your place

Agree - we are not doctors. I have no issue with this. It seems that the newer NPs sometimes take issue with this. I have to say that as FullGlass is a direct entry NP so without RN experience, it would be difficult to perhaps discern the difference? (I am not being snarky - I'm simply stating that if you have no NURSING experience, you might easily equate yourself to an MD?)

For those of us with years of APRN experience, it is readily apparent that we are not equal to MDs or DOs. However, we still have a place as providers in our healthcare system.

All I can say is there is room for all of us.

[TuxnadoDO]

Agreed. So much respect for you, btw. Your experience obviously informs your perspectives and I’m glad your voice is here.

[guest478081]

8 hours ago, TuxnadoDO said:

Agreed. So much respect for you, btw. Your experience obviously informs your perspectives and I’m glad your voice is here.

9 hours ago, traumaRUs said:

Agree - we are not doctors. I have no issue with this. It seems that the newer NPs sometimes take issue with this. I have to say that as FullGlass is a direct entry NP so without RN experience, it would be difficult to perhaps discern the difference? (I am not being snarky - I'm simply stating that if you have no NURSING experience, you might easily equate yourself to an MD?)

For those of us with years of APRN experience, it is readily apparent that we are not equal to MDs or DOs. However, we still have a place as providers in our healthcare system.

All I can say is there is room for all of us.

I think trauma may be right. FG seems to have gone back into healthcare in middle age and may bring along some baggage from a previous career and also seems to have skipped out on the RN aspect of nursing aka the backbone. To those out there who are not nurses remember these people are in the minority of the nursing world and most of us are fine with providing an important but non physician aspect to healthcare. We also mostly don’t find the need to acquire self actualization by trying to one up the physicians we work with on a forum. TBH all the nurses trying to act like doctors seem to be the ones who’s career defines them and are WAY too happy with their credentials. Get out and enjoy life a little bit

[traumaRUs, MSN, APRN]

2 hours ago, kudzui said:

I think trauma may be right. FG seems to have gone back into healthcare in middle age and may bring along some baggage from a previous career and also seems to have skipped out on the RN aspect of nursing aka the backbone. To those out there who are not nurses remember these people are in the minority of the nursing world and most of us are fine with providing an important but non physician aspect to healthcare. We also mostly don’t find the need to acquire self actualization by trying to one up the physicians we work with on a forum. TBH all the nurses trying to act like doctors seem to be the ones who’s career defines them and are WAY too happy with their credentials. Get out and enjoy life a little bit

Exactly! Nursing is a second career for me also but I came up thru the ranks so to speak (my prior career was the USN). FullGlass is probably an excellent NP. However, without the nursing experience interacting with MDs/DOs, med students, residents, etc., I think sometimes he/she may miss out on the back-story.

This is not a slam to direct entry NPs, just simply my observation. Thank you TuxnadoDO - my nephrologists are very happy with the care I provide OUR patients - we are a team, we do what needs to be done to get the care required for our patients. In my area, when I'm ask what practice I work for, there is always positive feedback as our practice as a whole is a cohesive group of nephrologists, surgeons and APRNs and PAs.

[guest478081]

And about one more thing

primary care easy? I believe kaiser in Cali has began replacing MLPs with almost all PCPs since their specialists where getting too many silly referrals for things that should have been managed by a PCP.

This is contrary to how it works but I always thought APP/MLPs where better utilized in specialty practice where the scope is narrower and they can collaborate more easily with their physician. Probably why the anesthesia route for nursing has been so successful. Yeah we can kill people quicker but our practice scope is so narrow it to make makes anesthesia probably Easier than primary care MOST times. Sure we line people all day with arts and cvcs and Intubate and all of those things that sound “cool” but let’s be honest the skill set required for GOOD primary care is much broader. Anyone can learn to stick a tube or line in but the cerebrating required for Good primary care is more abstract

To say primary care is easy is a novice statement. It’s easy to do it wrong without instant repercussions but over long periods of time can be devastating to a community to practice bad medicine. People confuse acuity with difficulty. Anesthesia is acute but most of the time not that difficult. PC is the opposite and please ask any rheumatologist if acuity equals difficulty in their practice