Physician Hostility - page 2

Why are so many physicians threatened and hostile toward NPs? What are the strategies in dealing with these types of professionals,and in what ways can we make it easier to practice together?... Read More

  1. by   zenman
    Originally Posted by blake: Why are so many physicians threatened and hostile toward NPs? What are the strategies in dealing with these types of professionals,and in what ways can we make it easier to practice together?
    This reminds me of the Oriental Medicine guys who are so upset that MDs are taking a 300 hour course in acupuncture as compared to their 3,200 hours. Maybe tenesma has some input from his perspective.
  2. by   Roland
    It wouldn't surprise me if those "oriental guys" wouldn't just come out and say "look giving a license to practice acupuncture to people who take less than ten percent of our training threatens our standard of living". People in other cultures are often more willing to "tell it like it is" than Americans.

    Another point that applies to this debate, namely the Law of Diminishing Returns. The closer one comes to perfection the more effort it takes to achieve continued results. This is why the last five pounds of weight loss on a diet are three times more difficult to obtain than perhaps the first twenty. This concept also applies to treating people. M.D.'s without question have more education than most N.P.'s, cetaris paribus. However, how much of this additional training correlates with increased patient outcomes? Furthermore, even if there IS a difference in outcomes is such a difference sufficient to off set the additional cost of physicians, and the impact on other patients of this cost? Consider ONE scenario: Let's say on average that ten physicians treat a thousand patients and are able to "save" nine hundred and fifty of them from death or morbidity. On the other hand NP's treat a thousand "theoretically identical" patients and are "only" able to save nine hundred and twenty patients. Thus, under this hypothetical scenario thirty more patients would have lived with M.D. treatment instead of NP treatment ( again I do not believe that N.P.'s would be less effective, but am stipulating to the argument of many M.D.'s for the sake of discussion). On the other hand the M.D.'s earn an average salary of $175,000 whereas the N.P. earn an average of $100,000 per annum or a difference of $75,000 per year. Thus, the NP's "cost" the health care system $750,000 per year less (as a group) in expenses than the M.D's (to say nothing of the higher costs associated with EDUCATING physicians relative to N.P's).

    Of course critics will say that you cannot measure the value of a human life in dollars and cents. However, let me ask this question instead. How many lives could be saved with the $750,000 saved by utilizing N.P's instead of M.D's? How could this money be allocated. Let's consider a few possible scenarios:

    1. It might fund a walk in clinic where people who would not otherwise have a "family doctor" are able to have a "family N.P.". Such a clinic might have a dramatic impact on morbidity and mortality in it's general area.

    2. It might be used to promote vaccination awareness, and free vaccine programs reducing infectious disease.

    3. It could pay for an "abundance" of high activity post MI (and better yet PRE MI in high risk CHD patients) medications such as statins, ACE inhibitors, beta-blockers, and good old aspirin for people who would otherwise not be able to afford this medication saving countless lives.

    4. It could pay for an additional Five N.P.'s (I say five instead of seven due to costs in hiring not reflected in salary). These N.P's could be engaged in a variety of settings from home visits (like Dr's used to do in the good old days before they got to expensive!) for the infirm to early pre-natal care preaching folic acid awareness straight to the people (saving untold millions in birth defects not to mention lives).

    You get the point, and I'm sure that these suggestions DO NOT represent the most efficient use of any such savings (which would probably be much higher than my estimates when education costs are factored into the equation). Thus, while you cannot put a price on human life we know that human life can be saved and sickness reduced by the judicious allocation of healthcare resources. Furthermore, ESPECIALLY if N.P.'s become leaders in the applications of scientifically supported (but clinically neglected) CAM interventions (and non CAM interventions such as the four drug post MI combo which is not being fully implemented by cardiologists despite the position of the AHA and other professional organizations) N.P.'s should be able to substantially IMPROVE upon the patient outcomes achieved by M.D.'s AND still save money (which I hope you will now see as largely synonymous with health care resources).

    The key is HONEST research that evaluates patient outcomes when treated by N.P's and M.D.'s. This is because EVEN IF discrepancies are found the Law of Diminishing Returns implies that they can be corrected through relatively modest interventions in N.P. training such as requiring addtional classes like gross anatomy, and advanced pathophysiology (and I don't believe they WILL be found). In addition, the economic arguments will also be made more credible by the obvious sincerity of such research.

    Some M.D's may argue that if M.D's are good in independent practice then so to are PA's. I would reply that they may indeed be correct! However, I suspect that M.D's will be even less willing to allow PA's into private practice than they will N.P's it would simply hit too close to home for many of them. In any case N.P's are still more efficient because they are built off an RN knowledge base (which is economically productive while learning) and because PA institutions tend to have higher rates of tuition (and hence economic cost). In any case the public will benefit from having more primary care resources, and N.P.'s should benefit from greater autonomy.
  3. by   zenman
    Posted by Roland: The key is HONEST research...
    What would "honest" research be? Is it even possible? Is the "scientic method" the best we've got?
  4. by   Tenesma
    zenman: in some states you don't need to be trained in acupuncture in order to practice acupuncture - just as long as you are an MD (ie: Massachusetts)... so how do those oriental practitioners w/ 3200 hours feel about that :uhoh21:
  5. by   Tenesma

    if you read the full text of JAMA 2000 (january): you will see that the study was not done in the emergent/acute setting, but rather at 4 different urban primary care sites, with primary treatment of hypertension and diabetes in a predominantly female hispanic population. You are right that that study reveals no difference in outcome.... especially regarding patient satisfaction.

    This in no way proves that NPs provide equivalent care, it does prove that NPs spend more time with the patient, and does order more studies/investigations...
  6. by   zenman
    zenman: in some states you don't need to be trained in acupuncture in order to practice acupuncture - just as long as you are an MD (ie: Massachusetts)... so how do those oriental practitioners w/ 3200 hours feel about that
    Here's an article:
  7. by   Tenesma
    zenman: i agree... just pointing out the poor standards expected of MDs in certain states...
  8. by   Roland
    Honest research implies studies conducted without obvious bias. In something so controversial as NP's verses M.D.'s I do not believe that this sort of research is likely to occur without a collaberative effort. The scientific method implies proposing a hypothesis, objectively testing, and then either accepting or rejecting your hypothesis based upon the data. How else would you go about fairly ascertaining the truth?

    I also think that if more NP's practice independently (along perhaps with PA's) that the public will ultimately benefit by having more primary care practitioners. Even the "competition" to improve patient outcomes should ultimately serve to make health care better for everyone. Furthermore, if such an effort stimulates physicians to move away somewhat from the "specializaton trend" and to more eagerly adopt CAM interventions (when supported by empirical research) everyone is also likely to benefit.
    Combine these sorts of initiatives with TORT reform and health care inflation could probably be brought under control.
  9. by   PA-C, DO
    I think physicians just cannot possibly understand how an NP can even feel comfortable practicing solo medicine. I mean come on, even right out of residency a physician is very green, and often needs to seek the advice of other physicians. How can an NP practice without knowing some of the more detailed pathophysiology taugth in medical schools? I am at least willing to admit that NP's probably get decent pharm and clin med courses compared to medical school, but without the detailed histo, path, embryo, immuno, how can one really feel confident that they know enough to practice alone? I just can't see why NP's feel the need to try and be autonomous when they are more useful working with physicians. The best NP's I have ever worked with were ones that were plenty smart enough to know that to be independent was simply dangerous. I mean if you are an NP, and the following terms are foreign to you, then my guess is you don't have the in depth knowledge necessary to practice as an independent practitioner.

    Rapidly progressive glomerulonephritis (RPGN)
    Focal Segmental Glomerulosclerosis (FSGS)
    Carcinoid Syndrome
    PTHRP secreting tumors of the lung
    MEN I II and III
    Waldenstrom's macroglobulinemia
    Prader Willi
    Pregnenelone pathway

    These are just off the top of my head, and are things that are common in my everyday vocabulary now, but were probably not known well to me as a PA-C when I was practicing. And the list could go on forever. PA school is way more rigorous than NP school and we all know that, but PA school is not even close to as detailed as medical school. Why can't NP's just agree that they provide excellent care when working with physicians? I would not have a problem hiring an NP in family medicine, OB, peds, but in IM, I would choose a PA, as well as in nephro, cardio, pulmo, gastro, any surgical field, and in EM I think the two are equal. But I worry about putting an NP in a rural setting alone because they have no supervisory requirements. At least a PA has to have the doc come by and sign charts, and collaborate from time to time. Well I hope I have not pissed off any of you NP's who really know your place in medicine, but I think the ones who are pushing for solo practice rights will never see eye to eye with me.
  10. by   Dave ARNP

    Someone tell me when NP school stoped teaching you how to be solo?
    Cause ya know... I learned that.

    PA-C, DO. What is your medical speciality? Just wondering.

    David Adams, ARNP
  11. by   Hellllllo Nurse
    PA-C, DO -

    I am an ADN RN, and several of the terms you listed are familiar to me. In fact, I have done tutoring on SIADH.

    Personally, I prefer to see an NP. Generally, they spend much more time w/ their pts, and do much better assessments and histories. And..... they don't have that "I can't be bothered" attitude that so many docs have.
  12. by   Hellllllo Nurse
    Do physicians deliver better care than Advanced Practice Nurses?

    The media sometimes suggests that physicians deliver better care than Advanced Practice Nurses (APNs). Is that true?

    Not according to most scientific studies, which have found that care by APNs is as good as or better than that of physicians.

    Some recent press articles have openly disparaged or devalued the care of APNs relative to that of physicians. And the government's slogan for their "Take Your Loved One to the Doctor" media campaign completely ignored APNs.

    However, the following studies and articles show that the care provided by APNs merits at least as much respect as that of their physician counterparts.

    Midwife care equal in morbidity at a lower cost, with more favorable outcomes and fewer interventions

    June 2003 -- The American Journal of Public Health published a study funded by the US Agency for Health Care Research and Quality of low-risk patients receiving collaborative/birth center/midwifery care who had comparable morbidity, preterm birth, and low-birth weight rates to patients receiving physician only care. Collaborative care also resulted in more favorable outcomes and a lower cost to the health care system through spending less time as an in-patient, fewer C-sections, episiotomies, inductions, and vacuum or forceps assisted vaginal births, and more prenatal services delivered despite the lower cost. more...

    Nurse-midwives transfer embryos at least as well as gynecologists

    May 2003 -- A clinical trial of 102 patients randomly assigned to receive embryo transfers from nurse-midwives or gynecologists found that clinical pregnancy rates were similar--31% for midwives and 29% for gynecologists. The study subjects had a high acceptance rate of midwives on a questionnaire. Bjuresten, K., Hreinsson, J. G., Fridstrm, M., Rosenlund, B., Ek, I. & Hovatta, O. (2003). Embryo transfer by midwife or gynecologist: a prospective randomized study. Acta Obstetricia et Gynecologica Scandinavica, 82 (5), 462.

    London patients rate nurse-led GYN clinics significantly higher than physician-led clinics

    April 2003 -- London scientists found that nurse-led GYN clinics had significantly higher patient satisfaction scores than physician-led GYN clinics. Patients rated nurse-led clinics higher in quality, competence, provision of information and overall satisfaction. Miles, K., Penny, N., Power, R. & Mercey, D (2003). Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire. Journal of Advanced Nursing, April, 42 (1), 64.

    Multiple studies find no differences between care delivered by Nurse Anesthetists and Anesthesiologists

    2002 -- See the American Association of Nurse Anesthetists' web pages comparing the care of Certified Registered Nurse Anesthetists to that of Anesthesiologists. A number of studies have found no significant differences in patient outcomes based on professional background.

    Meta-analysis: NP patient satisfaction higher and care equal to or better than MD care

    April 2002 -- In a meta-analysis of 34 clinical studies published in the British Medical Journal by Horrocks, Anderson & Salisbury comparing care by NP's and physicians, researchers found that patients were more satisfied with their care if it was delivered by a Nurse Practitioner (NP) than by a physician. Compared to physicians, NP's read X-rays equally well, identified more physical abnormalities, communicated better, gave patients more information and taught patients how to provide self-care better. NPs also "undertook more investigations" and spent significantly more time with patients, 14.9 minutes vs. 11.2 minutes for physicians.

    Nurse experts interviewed on nurse practitioner and physician care differences

    January 14, 2002 -- Linda Aiken Ph.D., RN and colleagues give a compelling interview to Medscape on differences in care delivery between nurse practitioners and physicians.

    Physicians: higher patient satisfaction; NP patients: lower blood pressure in study

    January 2000 -- M. Mundinger et al. from Columbia University School of Nursing published a randomized clinical research study of 1316 patients in the Journal of the American Medical Association (2000). The study compared care between nurse practitioners and physicians. Patients answered a satisfaction questionnaire after initial appointment and were examined 6 months and 1 year later. At six months, physicians received a significantly higher satisfaction rating (4.2 vs. 4.1 on a 5.0 scale). There were no utilization differences, and the only health status difference was that patients with high blood pressure who were cared for by nurse practitioners had significantly lower diastolic blood pressures.

    Advanced Practice Nurses: better compliance, higher satisfaction in meta-analysis

    November 1995 -- Brown & Grimes from the Univ. of Texas at Austin School of Nursing published a meta-analysis of 33 randomized studies comparing the outcomes of primary care patients of nurse practitioners (NPs) and nurse midwives (NMs) with those of physicians in the journal Nursing Research. Patients of NPs had significantly greater patient compliance with treatment recommendations compared to physicians. In controlled studies, patients of NPs had greater patient satisfaction and resolution of pathological conditions than patients of physicians. Most other variables were similar. NMs used less technology and analgesia during labor and delivery than did physicians, and the two groups of providers had babies with similar outcomes.

    NPs--better patient education, care continuity, knowledge about disease, less waiting

    October 1995 -- Langner & Hutelmyer published the results of a patient satisfaction survey of 52 HIV-infected primary care patients at an urban medical teaching clinic in the journal Holistic Nursing Practice. Patients of nurse practitioners "fared more favorably" in clinic waiting time, provider knowledge about the disease, continuity of care, and patient education when compared to physician providers.

    2003-2004 The Center for Nursing Advocacy, Inc. All Rights Reserved.

    Study: Nurse practitioners equal to doctors in some cases

    Proponents of nurse practitioners say their training places greater emphasis on disease prevention

    January 5, 2000
    Web posted at: 3:35 p.m. EST (2035 GMT)

    In this story:

    'High quality, competent providers of primary care'

    'I do have limitations'

    Findings and drawbacks



    CHICAGO (CNN) -- Nobody says, "I have a nurse's appointment," but a controversial study suggests patients who have asthma, diabetes or high blood pressure and receive primary care from nurse practitioners fare just as well as those treated by doctors.

    The study was published in this week's Journal of the American Medical Association, which also carried an editorial warning against reading too much into the findings.

    CNN's Rhonda Rowland reports on the use of nurse practitioners in many medical practices.
    Real 28K 80K
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    The editorial said it is unclear whether the results of the six-month study -- which involved mostly poor, Hispanic women in their 40s -- are representative of the population at large or whether the results would be the same over longer periods, when more complex medical problems might arise.

    'High quality, competent providers of primary care'
    The study involved 1, 316 patients who visited a hospital emergency department or urgent care center within the Columbia Presbyterian Medical Center system in New York.

    Of the patients, 510 were assigned to doctors while 806 were assigned to nurse practitioners.

    After six months, it was determined that patients in both groups got equal benefit medically and were just as satisfied.

    Who are nurse practitioners?
    * Registered nurses with advanced, specialized training in primary care

    * Often practice medicine without doctor supervision

    * Tend to spend more time with each patient

    * Licensed in all 50 states

    * Can write prescriptions in every state, although four -- Pennsylvania, Georgia, Michigan and Ohio -- require a doctor to co-sign the order

    * About 65,000 nurse practitioners work in the United States

    Read the study comparing nurse practitioners with doctors

    Proponents of nurse practitioners say their training places greater emphasis on disease prevention, risk reduction and empowering patients to care for themselves.

    "This study adds strong science to earlier studies that suggest nurse practitioners are high quality, competent providers of primary care who can achieve the same health outcomes physicians can," said the lead author, Mary Mundinger, professor of health policy and dean of the Columbia University School of Nursing in New York.

    Dr. Wilma Lee, an obstetrician/gynecologist at the Emory Clinic in Atlanta, which was not involved in the study, agrees that six months is not long enough for an accurate accounting of health benefits, but says the findings match what she's seen in her own practice.

    "The average ob/gyn practice is more similar to this population because it is overall a well practice, they're usually patients who are not acutely ill," she told CNN.

    'I do have limitations'
    Mundinger said more than 100 studies had been conducted over the past 30 years measuring nurse practitioner competence among patients from all walks of life, in all parts of the United States and with all age groups, including children.

    "In the context of all those other studies, this strongly suggests that nurse practitioners with other populations will do just as well," she said.

    Kathryn Rowan, a nurse practitioner at the Emory Clinic, is encouraged by the findings, but does not think they suggest nurses should replace doctors.

    "Personally, I would never want to be in a position where I didn't have a physician to consult with," she said. "I've been doing this for a number of years and feel I do have limitations."

    Most of the patients in the study were Hispanic women

    Findings and drawbacks
    The study, conducted between 1995 and 1997, found:

    * The nurse-practitioners' patients fared as well medically -- measured by breathing capacity in asthmatics, blood-sugar control in diabetics and blood pressure in people with hypertension -- as the doctors' patients.

    * The two groups of patients also had similar rates of referrals to specialists, hospitalizations and costs, and they were equally satisfied with caregivers.

    "This study is a remarkable accomplishment, the most ambitious and well-executed comparison of nurse practitioners with physicians," an expert not involved in the work, Dr. Harold Sox of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, said in the accompanying editorial.

    But Sox said the patients were a select population -- they were younger, mostly female, Spanish-speaking and on Medicaid -- and that a six-month study may not have been long enough to see the full spectrum of complex medical problems such patients could face.

    Correspondent Ronda Rowland and The Associated Press contributed to this report.
  13. by   Dave ARNP
    Quote from Hellllllo Nurse
    PA-C, DO -

    I am an ADN RN, and several of the terms you listed are familiar to me. In fact, I have done tutoring on SIADH.

    Personally, I prefer to see an NP. Generally, they spend much more time w/ their pts, and do much better assessments and histories. And..... they don't have that "I can't be bothered" attitude that so many docs have.
    Helllllo Nurse,
    I am so glad I wasn't the only one who recognized those terms. I beat ya though, I got ALL of them .

    Would you ever have dreamed that little ol RN's and NP's would be able to grasp these concepts?

    Shocking... I know.