An article appeared today in the New York Times as a followup to a bill passed in New York granting nurse practitioners the right to provide primary care without the oversight of a physician. The authors of the bill state "mandatory collaboration with a physician no longer serves a clinical purpose and reduces much-needed access to primary care". The need for more primary care providers is due to the shortage of primary-care physicians, the aging boomer population, and the Affordable Care Act.
Although the president of the American Association of Nurse Practitioners feels that the current "hierarchical, physician-centric structure" is not necessary, many physicians disagree citing that the clinical importance of the physician's expertise is being underestimated and that the cost-effectiveness of nurse practitioners is being over-estimated.
Many physicians also feel that "nurse practitioners are worthy professionals and are absolutely essential to patient care. But they are not doctors."
What are your thoughts on this? Where do nurse practitioners fit into the healthcare hierarchy?
They may not fill initially, but they 100% fill by the time residency starts July 1.
Actually, that is not true according to the statistics that I posted from the national residency matching program. Many of these residency positions are filled by foreign trained physicians too.
I think an issue that has failed to be addressed (or maybe it has and I’ve neglected to find it among the pages of comments this thread has generated) is that Nurse Practitioners and Physicians have different philosophies and different focuses. We are, essentially, comparing apples to oranges. Compared side-by-side, NP and MD’s may share certain “scope of practice” tasks, but on a whole, their guiding principles are different. This being the case, what, exactly, is the issue in NPs being allowed to practice sans a collaborative agreement? As many others have noted, MDs utilize “collaborative agreements” within their practice almost daily, but this is akin to a “consult” as opposed to having someone “sign off” on ones orders, diagnostics, or treatment plan. If an NP is practicing sans a collaborative agreement, yet chooses to order a consult to a specialist, or an MD, how is this any different than the means by which MDs practice?
Education, you say? I’ve seen many individuals, in different professions outside of healthcare that have acquired many degrees and logged many hours in their general field, and this does not an expert make. Education does not always equal mastery of practice, knowledge of theory, or skill. Of course, there are exceptions to every rule, but I think each and every one of us can think of someone who has “book smarts,” but not necessarily the common sense to execute it well. It is not just having the know-how but also being able to properly utilize critical thinking skills. One of my favorite instructors once noted that a nurse can be “book smart” in her own right, and that can be taught, but critical thinking and bedside manner cannot be.
I find it hard to imagine that the reasons MDs are concerned for the lack of this collaborative agreement is for the concern of patient outcomes. There has to be some deeper rationale, truly. To be completely blunt, for the majority, I don’t think it would matter the level of required education for an NP. Once the word “nurse” has been utilized, all respect or acknowledgement for skill level and clinical knowledge goes completely out the window. Agree or disagree, but the divide among nurses and physicians has existed for far longer than the concept of “collaborative agreements” has been around.
Those are statistics are the results from the NRMP match, not the Scramble afterwards. Like I said, those spots fills many times, with foreign medical graduates. They are also doctors as well.
Actually, that is not true according to the statistics that I posted from the national residency matching program. Many of these residency positions are filled by foreign trained physicians too.
Those are statistics are the results from the NRMP match, not the Scramble afterwards. Like I said, those spots fills many times, with foreign medical graduates. They are also doctors as well.
The point is still the same. Most physicians chose not to train or work in FP, especially U.S. trained physicians. There are more opportunities for healthcare providers in FP than physicians can possibly hope to fill, and there is no research that shows that forcing NPs to have collaborative agreements help patients or the healthcare system. There is in fact research that shows that independent NPs can and do provide just as superior care as physicians, and that independent NPs are viable solution to the shortage of providers in Family Practice.
The point is still the same. Most physicians chose not to train or work in FP, especially U.S. trained physicians. There are more opportunities for healthcare providers in FP than physicians can possibly hope to fill, and there is no research that shows that forcing NPs to have collaborative agreements help patients or the healthcare system. There is in fact research that shows that independent NPs can and do provide just as superior care as physicians, and that independent NPs are viable solution to the shortage of providers in Family Practice.
Did you not see the graph in page 7 on the discrepancy between Total Applicants and Total PGY-1 positions?
Yeah and all that research on outcomes is funded by nursing interest groups who have a direct stake in the research involved, are very short in length - 6 mos. to 1 year which are like nothing, and are on terrible endpoints like blood pressure, hemoglobin A1C and not actual outcomes like mortality. Yet when DNPs took a certification exam similar to USMLE Step 3 - 50% of them failed: http://www.cumc.columbia.edu/nursing/dnpcert/rates.shtml
Specializes in Pediatrics, High-Risk L&D, Antepartum, L.
Did you not see the graph in page 7 on the discrepancy between Total Applicants and Total PGY-1 positions?
Yeah and all that research on outcomes is funded by nursing interest groups who have a direct stake in the research involved, are very short in length - 6 mos. to 1 year which are like nothing, and are on terrible endpoints like blood pressure, hemoglobin A1C and not actual outcomes like mortality. Yet when DNPs took a certification exam similar to USMLE Step 3 - 50% of them failed: http://www.cumc.columbia.edu/nursing/dnpcert/rates.shtml
And are there for MDs, residents, interns and such to compare? How am I to know how the docs did?
Did you not see the graph in page 7 on the discrepancy between Total Applicants and Total PGY-1 positions?
Yeah and all that research on outcomes is funded by nursing interest groups who have a direct stake in the research involved, are very short in length - 6 mos. to 1 year which are like nothing, and are on terrible endpoints like blood pressure, hemoglobin A1C and not actual outcomes like mortality. Yet when DNPs took a certification exam similar to USMLE Step 3 - 50% of them failed: http://www.cumc.columbia.edu/nursing/dnpcert/rates.shtml
We have resorted to the conspiracy theory response to refute the data? Do you think the landmark study, published in the JAMA, was pushed through with flawed data by the uber powerful nursing interest groups? We are talking about the AMA which dwarfs all the nursing interest groups combined.
So if the data is flawed, please cite the studies that have been published refuting the data.
Those "like nothing" endpoints you listed (and the JAMA study used the SF-36) are responsible for how much cost and morbidity in the US?
Select a Year, and click on the USMLE Step 3 tab - where 96% of MD and 92% of DO candidates pass. The exam is taken during residency.
Where is your evidence that the USMLE Step 3 predicts patient outcomes better than the NP board exams? MD/DOs take USMLE exams. NPs take their speciality board exams.
Select a Year, and click on the USMLE Step 3 tab - where 96% of MD and 92% of DO candidates pass. The exam is taken during residency.
Oh no I don't want to see how they did on a similar exam...same exam. Similar...not close enough for me actually.
Also, is there data showing that passing the exam means excellent provider? Oh right...there isn't because lots of crap doctors out there.
So similar exam and you believe the exam means excellent outcomes. Huh? How does that work for a legal defense? He passed the exam...so he's great! Yeah...no.
wtbcrna, MSN, DNP, CRNA
5,128 Posts
Actually, that is not true according to the statistics that I posted from the national residency matching program. Many of these residency positions are filled by foreign trained physicians too.