I HATE Nurse Practitioners

allnurses Guide · Mar 15, 2015

It seems the NPs are much quicker to refer a patient to a specialist before acquiring enough diagnostic workup to justify the referral, compared to their MD counterparts. For example, if a patient has back pain, the NP would possibly order some x-rays of the spine, and then refer to a spine surgeon regardless of the results of the x-ray; whereas, the primary care MD would work it up further with additional MRIs, etc, before considering referring.

Anecdotally I would agree with your observations. In my experience FNPs in particular seem fairly heavy handed with the diagnostics and specialist referrals as compared to physicians.

For what it's worth, the extant literature on the topic has been fairly consistent in demonstrating similar usage of diagnostics, actually one major study demonstrated that those MRIs being ordered by the PCP lead to a higher cost to the system over a specialty referral.

I am curious Jules, you work in psych correct? Where do you see FNPs over ordering diagnostics?

Jules A, MSN · Mar 16, 2015

I am curious Jules, you work in psych correct? Where do you see FNPs over ordering diagnostics?

I work part-time in a pediatrician's office and at another job a majority of my patients are seen by two hospital affiliated practices staffed by FNPs. Our medical record system is the same and probably 50% of my patient's PCPs are Nurse Practitioners.

My biggest concern is overuse of xrays and CTs for children and I wonder if NPs cave to parental insistence for diagnostics more than physicians. I was only speaking anecdotally so if you have research that indicates otherwise thats fair enough.

tobra99 · Mar 16, 2015

For what it's worth, the extant literature on the topic has been fairly consistent in demonstrating similar usage of diagnostics, actually one major study demonstrated that those MRIs being ordered by the PCP lead to a higher cost to the system over a specialty referral.
I am curious Jules, you work in psych correct? Where do you see FNPs over ordering diagnostics?

I am not asserting that FNPs are over-ordering diagnostics. Instead, I am saying that they seem to under-workup cases with the appropriate diagnostics, and instead refer to a subspecialist early, compared to their primary care physician counterparts.

This is not necessarily a bad thing, as it probably will not affect patient outcomes, because the appropriate work-up will be done either way, whether by the primary care provider or a specialist. But the quickness to refer to specialists may offset the cheaper cost of healthcare that NPs provide. However, I admit this is just based on my observations which may very well be subject to sampling bias.

anh06005, MSN, APRN, NP · Mar 17, 2015

I just want to commend Boston and Tobra for having a mature disagreement without name calling.

It's a bit refreshing.

RosalynLee · Mar 17, 2015

I'm sorry I couldn't disagree with you more. I don't care what they think and I'm not going to hold back on my goals because of it either. I don't give in that easy, sorry...NPs are the future in a world where primary care physicians are severely short and we're able to do jobs that aren't rocket science for cheaper.

allnurses Guide · Mar 17, 2015

I am not asserting that FNPs are over-ordering diagnostics. Instead, I am saying that they seem to under-workup cases with the appropriate diagnostics, and instead refer to a subspecialist early, compared to their primary care physician counterparts.
This is not necessarily a bad thing, as it probably will not affect patient outcomes, because the appropriate work-up will be done either way, whether by the primary care provider or a specialist. But the quickness to refer to specialists may offset the cheaper cost of healthcare that NPs provide. However, I admit this is just based on my observations which may very well be subject to sampling bias.

There is some research to support that NPs tend to refer more as well as have more "unnecessary" referrals, though this has not been the case in all studies. Form professional experience, it probably is true, especially with new-to-practice NPs. I wonder if the same study was done on residents if the numbers would be similar, as both novice NPs and medical residents are competent but comparatively inexperienced providers.

The overall cost to the system is what is important from my perspective. Over-referring is costly but over-ordering diagnostics can be as well, especially when those diagnostics demonstrates a subsequent need for referral. It is a complicated issue and one I am sure will continue to be evaluated as care moves towards ACOs.

My colleague physician and I discuss this fairly often as he tends to order more specialized diagnostics where I tend to do a basic workup and refer if I think the trajectory is headed that way regardless. If you were a patient would you prefer your PCP refer you fairly quickly to a specialist or spend 4-6 weeks working you up before eventually referring you (if indicated)?

Then there is the issue of NPs working in specialty settings, which further complicates things.

tobra99 · Mar 17, 2015

There is some research to support that NPs tend to refer more as well as have more "unnecessary" referrals, though this has not been the case in all studies. Form professional experience, it probably is true, especially with new-to-practice NPs. I wonder if the same study was done on residents if the numbers would be similar, as both novice NPs and medical residents are competent but comparatively inexperienced providers.
The overall cost to the system is what is important from my perspective. Over-referring is costly but over-ordering diagnostics can be as well, especially when those diagnostics demonstrates a subsequent need for referral. It is a complicated issue and one I am sure will continue to be evaluated as care moves towards ACOs.
My colleague physician and I discuss this fairly often as he tends to order more specialized diagnostics where I tend to do a basic workup and refer if I think the trajectory is headed that way regardless. If you were a patient would you prefer your PCP refer you fairly quickly to a specialist or spend 4-6 weeks working you up before eventually referring you (if indicated)?
Then there is the issue of NPs working in specialty settings, which further complicates things.

I think I would agree with you that medical residents would also be quick to refer to subspecialists early. Anecdotally, I have worked in hospitals where the ER is primarily run by residents, and I do recall that the ER residents would consult a specialist for almost everything and anything. In the hospitals I work in now, there are no ER residency programs, and the ER attendings seem much more able to handle moderately complex issues without obtaining a consult. However, for true cost and outcome analysis, the comparison here needs to be between NPs and fully-trained primary care attending physicians, as residents are still just in training.

I am a neurosurgeon who receives many referrals from both primary care physicians as well as NPs. I would estimate that 60-70% of the patients referred to me by primary care MD's actually have a neurosurgical issue. That rate seems to be signicantly lower for the patients referred to me by NPs, meaning more of those patients never needed formal evaluation by a neurosurgeon and would have done well with appropriate workup and conservative management by their primary care provider.

Because I bill for the consultation for each patient even if they have no neurosurgical issue, that may result in a lot of costly but unnecessary visits to the neurosurgeon (but means more business for me :) ), where I would just end up ordering the diagnostic tests anyway. For those patients, diagnostic workup + unnecessary neurosurgical eval would cost signficantly more than diagnostic workup alone, regardless of who is ordering the diagnostic workup.

Keep in mind that these numbers I am spitting out are just my estimates. I would have to go back to my records to see the actual numbers, but maybe it would be an interesting cost analysis for the future.

Also I hope anyone reading these posts doesn't think I'm against the concept of NPs in anyway. I do think NPs are the future of primary care. I post here because I have been curious about the nursing perspective for a while, and also because I have a poor social life these days.

greygooseuria · Mar 17, 2015

I agree with tobra to a degree, and think some of it may be sampling bias (you may have a lot of new grad NPs in your area). I've been an NP for two years and during my first year of practice I was definitely referring to specialists a lot; however, once I got a hold of the common things I was referring out for and saw the specialists' notes, I started prescribing the treatment the specialists did for previous similar cases and this cut my referrals down as I got used to seeing things.

I will say that anecdotally, I tend to take a patient's complaints more serious than some of my MD counterparts. I've diagnosed many cases of cancer, brain tumors, etc. that were actually mild office complaints (double vision, abdominal pain). I actually find that the MDs I work with that won't let me see their patients will let a patient crash and then send them to the ER rather than treat in house (I am in a SNF) whereas the MDs that DO let me see their patients have better outcomes, reduced rehospitalization, and shorter rehab stays.

MollyJ · Mar 18, 2015

I live in a psychiatrically underserved area and the bulk of psych care given to _children_ in our area is given by mid-levels.

God bless them.

This is what I will say.

My mid-level colleagues do help a lot of people but we have a significant number of children in our area who are high complexity and require expert psychiatric care. I worry about a situation where the most vulnerable children are being cared for by the least educated practitioner.

I would also say my mid-level colleagues are under supported by their advising docs who physically remote from where they practice and may infrequently see or never see their high complexity patients.

It's not an optimal situation.

allnurses Guide · Mar 18, 2015

Sorry for my delay in getting back to this, I have had a full panel of hospital pts as well as clinic so it's been a busy few days.

I wanted to respond to this in a few pieces and try and generate some discussion as I think these are good topics to discuss.

I think I would agree with you that medical residents would also be quick to refer to subspecialists early. Anecdotally, I have worked in hospitals where the ER is primarily run by residents, and I do recall that the ER residents would consult a specialist for almost everything and anything. In the hospitals I work in now, there are no ER residency programs, and the ER attendings seem much more able to handle moderately complex issues without obtaining a consult. However, for true cost and outcome analysis, the comparison here needs to be between NPs and fully-trained primary care attending physicians, as residents are still just in training.

I would argue that perhaps it shouldn't exclude residents. If novice NPs in the first three years of practice are similar in referral rates to 1st-3rd year residents and experienced NPs (4 or more years of experience) are similar to an attending primary care physician then the net cost to the system is exactly the same isn't it? NPs may over-refer in the first three years of practice just as medical residents due. That cost would then be a standard cost associated with training a new provider. I would be much more interested to see the data betwene experienced (>4 years) NP and attending MD.

I am a neurosurgeon who receives many referrals from both primary care physicians as well as NPs. I would estimate that 60-70% of the patients referred to me by primary care MD's actually have a neurosurgical issue. That rate seems to be signicantly lower for the patients referred to me by NPs, meaning more of those patients never needed formal evaluation by a neurosurgeon and would have done well with appropriate workup and conservative management by their primary care provider.

This anecdote is actually strikingly on-par with the literature that is out there; the "inappropriate" referral rate is about 36%. Interestingly enough, of that 36% the generalist and specialist disagreed about the "inappropriateness" of the referrals 34% of the time. The study actually states a very interesting conundrum that is the catch-22 of this debate:

" Both underreferral and overreferral can affect quality of care. Underreferral can lead to inappropriate, cost-ineffective, or even dangerous treatment, and may result in costly litigation.18 Overreferral can lead to fragmented care by committeeâ€; overtesting and repetitive testing; dangerous polypharmacy; patient confusion and isolation; and complacency on the part of generalists who lose their motivation to continually acquire new knowledge."

Personally, I would rather provider that was unsure of the correct course of action refer me!

Because I bill for the consultation for each patient even if they have no neurosurgical issue, that may result in a lot of costly but unnecessary visits to the neurosurgeon (but means more business for me :) ), where I would just end up ordering the diagnostic tests anyway. For those patients, diagnostic workup + unnecessary neurosurgical eval would cost signficantly more than diagnostic workup alone, regardless of who is ordering the diagnostic workup.

Have you every seen patient that have been referred and have had inappropriate MRI's or other expensive diagnostics ordered? I guess in my mind I always think of the cost/benefit: an MRI bills out at $2600 while a consult is typically less than $400. I don't think I would ever refer to neurosurgery without an MRI but i often do to orthopedics. Every patient wants an MRI when something is wrong but often that MRI isn't needed so I would rather refer them to the orthopod to confirm my diagnosis if the patient insists on an MRI. I could order the MRI to show them nothing is wrong, but it would cost 4-5 times more. That same study showed that 3% of all referrals were for non-medical reasons and only 20% were for only medical reasons. Patient pressure, as much as we all want to say it doesn't matter, does. Just look at what PG scores have done to ED practice.

Keep in mind that these numbers I am spitting out are just my estimates. I would have to go back to my records to see the actual numbers, but maybe it would be an interesting cost analysis for the future.

It would make for an interesting study to take those numbers and evaluate them using the cost of the pre-consult workup to the consult fee plus additional work-up. That would still leave out the cost associated with mis/delayed diagnosis, but it would be interesting.

Also I hope anyone reading these posts doesn't think I'm against the concept of NPs in anyway. I do think NPs are the future of primary care. I post here because I have been curious about the nursing perspective for a while, and also because I have a poor social life these days.

What social life?

Donohoe, M. T., Kravitz, R. L., Wheeler, D. B., Chandra, R., Chen, A., & Humphries, N. (1999). Reasons for Outpatient Referrals from Generalists to Specialists. Journal of General Internal Medicine, 14(5), 281â€“286. doi:10.1046/j.1525-1497.1999.00324.x

allnurses Guide · Mar 18, 2015

I live in a psychiatrically underserved area and the bulk of psych care given to _children_ in our area is given by mid-levels.
God bless them.
This is what I will say.
My mid-level colleagues do help a lot of people but we have a significant number of children in our area who are high complexity and require expert psychiatric care. I worry about a situation where the most vulnerable children are being cared for by the least educated practitioner.
I would also say my mid-level colleagues are under supported by their advising docs who physically remote from where they practice and may infrequently see or never see their high complexity patients.
It's not an optimal situation.

I cringe when I see people use "mid-level" like this; that's a whole different issue.

Least educated practitioner: what does the data show about the outcomes, regardless of education, between NPs, PAs, MDs, and DOs?

If the "advising" docs are remote and have never seen these highly complex patients then should those NPs have to pay those docs 50-100k per year?

And if it wasn't for these "least educated mid-levels" what would happen to these kids?

allnurses Guide · Mar 18, 2015

I just want to commend Boston and Tobra for having a mature disagreement without name calling.
It's a bit refreshing.

We are professionals! I have disagreements with docs (and other NPs/PAs) all the time regarding all sorts of things and I never hesitate to challenge them on it, but I never do so disrespectfully as we all have the same goal we just have a different approach.