Physician Hostility

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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?

Post by tenesma: which studies are those???

Come on Doc, just go here http://www.google.com and type in "effectiveness of nurse practitioners" and you'll be busy for a week. :coollook:

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.

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.

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?

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:

globalRN:

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...

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: http://www.acupuncturetoday.com/archives2004/mar/03amaro.html

zenman: i agree... just pointing out the poor standards expected of MDs in certain states...

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.

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

SIADH

Goodpastures

Wegener's

Waldenstrom's macroglobulinemia

GP41

Her2/Neu

P53

Prader Willi

Pregnenelone pathway

Finasteride

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.

Gee....

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

ACNP, FNP

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.

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