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?
As I said before, I think these types of discussions are important ones. I am glad there are some crossovers here discussing the issue and I think it has been a good debate (from most). Sadly, even at the state level (as least from my state NP association) there is a lack of interactive interdisciplinary dialogue on the topic.
Personally I have no desire to work "autonomously". I use the word in quotes because, for me, "autonomous" practice would me owning a business/practice, which I have no desire to do (and not have my ICU notes cosigned). I work with two physicians in a large practice that are both well over retirement age than have searched for another MD for the past 6 years with no luck. If they retire what happens to their practice? I am out of a job and all the patients are on their own to find a new PCP, which is limited in our area despite being a medical mecca. The other option is we keep the practice (the NPs/PAs) and pay $10-15k a quarter to have a physician "review" charts for an hour. Are any of these good options?
I agree with you - neither of those sound like good options. While it is my personal opinion and a matter for another debate entirely, I think that the 'work' some physicians do to review charts is garbage. It's a quick way to grab cash and not really do any work. It defeats the purpose of having a more expansive education; if a physician doesn't actually see the patient, how is he or she supposed to notice the rare disease at all? At the same time, I do realize there is a shortage of healthcare providers and the physicians here in the US would not be able to manage it alone.
It is a matter of semantics in some manner but it is also a bit of a precarious positions for most physicians: they want to acknowledge the quality and cost effective care NPs provide because they want to utilize NPs to make their practice money (I don't think anyone will argue that NPs provide practices with excellent ROI) but they don't want that quality and cost effective care to be independent of them because they lose that benefit. If the studies were on BP alone that's one thing, but the studies have demonstrated similar results across nearly every objective quality measure from BP to A1C to hospital readmission rates to SF-36 results to COPD management and so forth. These are major chronic conditions at big costs to the healthcare system as well as pateint morbidity and mortality.
Agreed completely about the financial part. The relationship between NPs and physicians was initially started to allow physicians to 'see' more patients, and thus increase their billables from insurance. I'm not a fan of that policy, but it speaks to the greater issue, which is the way health care is reimbursed - quantity, not quality.
I don't think chronic conditions are the issue. Once a problem has been identified, NPs can definitely manage the patient. I think where the physicians would stand out is with diagnosis of obscure disorders that many people won't see often. For example, one psychiatrist I know just told me the other day about a couple of patients that presented with pheochromocytoma, which appeared to be panic disorder. He said that he had only ever seen two cases of this in his entire career, and the only thing that differentiated them from his other panic patients was their prodigious diaphoresis. These are the kind of cases that a physician is more likely to catch.
I am sure we actually agree on 99% of diagnosis and treatment in primary care, though in this debate no one wants to admit that.
I would agree with that.
I am curious, if NPs do a fabulous job of managing chronic conditions studied (HTN, HL, DM, COPD, obesity, asthma, depression, anxiety, arthritis, preventative medicine) how does that not equate to the ability to provide fabulous primary care. These diagnosis make up the vast majority of primary care and chronic disease management and are directly responsible for the vast amount of complications our healthcare system faces. What about this does not mean quality primary care?
Like I said, managing previously diagnosed conditions (or diagnosing common presentations) is not a weakness of NPs. In fact, I would say that if a patient comes to clinic for the sole reason of a checkup for their chronic condition, they most likely don't need to see a physician. New sick visits are something about which I would be more wary.
Wait, who funds clinical trials for medications being approved by the FDA?
Some are funded by drug companies themselves, like I mentioned, but a big chunk of them are funded by the NIH.
No matter how good you are you have missed a diagnosis, I am sure I have and I am willing to bet you are sure you have to. It, unfortunately, happens. I find that spending more time with patients than my physician counterparts that I discover many of them.
Agreed. I'm sure most physicians would love to be able to spend more time with their patients, but hospitals push them to go as quickly as possible, and billing in private practice pushes them in the same direction.
It is difficult to comment about this because those studies (to my knowledge) just haven't been done. I have never seen any data that links NPs to more missed diagnoses than physicians. Do you think there is an increased in missed diagnoses when a provider sees 16 patients a day compared to seeing 20 patients a day? I would venture to guess there is, but I don't' see physicians arguing that they should see no more than "x" patients a day.
I agree with you. Seeing more patients each day leaves less time for each patient, and will lead to missed diagnoses. It's a problem, in my opinion.
That education and exposure is impressive, I don't think anyone (seriously) debates that. The debate for me is whether that education and exposure provides primary care patients with better outcomes or a bigger bill.
There are a lot of problems in healthcare today, but I don't think overeducated physicians are one of them. I think the bigger bills are more likely due to physicians that are more interested in money and performing procedures for which they can bill insurance, even if the procedures aren't necessary. Someone earlier in this thread mentioned a hip replacement for someone with end stage dementia - a perfect example of something I would deem completely unnecessary, and something done simply to get the physician money. This practice needs to be halted.
And for the record, most practicing NPs do no work in a specialty (from that last set of data I saw) and for the most part are educated and trained as generalists, save perhaps for psych NPs.
This says 30-35% are still in primary care. I didn't read very far, though.
Do you think the dermatologist who has been in practice for 30 years could walk into a internal medicine clinic and provide quality IM care?
A dermatologist that has been in practice for 2 years couldn't provide quality IM care - they weren't trained in that specialty. They would most likely provide care on a similar level to a second year resident, which is where they were at the end of their general training as an intern. Who knows, maybe I'm selling them short.
I would argue that the patients that fall through the cracks warrant more time spent with a provider and better access to healthcare.
Agreed. I believe we just disagree on what is the best solution to that.
You cannot cite what it is that NPs do not know. You refute every scientific study done showing that NPs provide quality care independent that is comparable to physician care, and no medical society has been able to produce a study to refute any of these findings, and yet it is the APNs that don't know we don't know. I know someone must have supersize ego to believe that in the face of overwhelming scientific evidence.
Having worked with physicians for over 16 years, trained with physicians, and went to some of the same medical school classes as physicians I would like to know where this secret physician only knowledge class is taught in medical school. I know for fact that when physicians need to look up something they utilize the same texts/reference materials as the rest of us.
1.Avorn, J., Everitt, D.E., & Baker, M.W. (1991) Interesting study, but performed 23 years ago. Who were these physicians and nurses? Study is subject to response bias. How do we know the physicians weren't just residents and the nurses had been in practice for 20 years? Would need to read the study.
2. Bakerjian, D. (2008) Nursing home care isn't complicated, doesn't require an MD to do.
3. Brown, S.A. & Grimes, D.E. (1995) 19 years old. Patient satisfaction is not a valid measure of outcome, though it is important in and of itself. This study includes midwives, so I'm not sure what they're actually studying.
4. Congressional Budget Office. (1979) 35 years old. The abstract doesn't include specifics, but I would imagine healthcare is much different now than it was then.
5. Cooper, M.A., Lindsay, G.M., Kinn, S., Swann, I.J. (2002) 12 years old, only 199 patients, again uses patient satisfaction as a measure of outcome.
6. Ettner, S.L., Kotlerman, J., Abdelmonem, A., Vazirani, S., Hays, R.D., Shapiro, M., et al. (2006) This study reveals cost savings when patients are sorted to a physician-NP model, not independent NP.
7. Horrocks, S., Anderson, E., Salisbury, C. (2002). Primary conclusion is that patient satisfaction is higher, and other outcomes did not have sufficient data to make conclusions. Does include that nurses order more tests.
8. Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2006) Intriguing study, but it doesn't mention which outcomes beyond patient satisfaction were measured.
9. Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin, S.X. (2004) Limited by only having two years of follow-up, but again does not list which outcomes have been measured. Interesting that it notes that patients treated by physicians had more clinic visits.
10. Lin, S.X., Hooker, R.S., Lens, E.R., Hopkins, S.C. (2002) Compares NPs to PAs, not physicians.
11. Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.Y., Cleary, P.D., et al. (2000) Six months of follow-up, and only examines patient satisfaction and health utilization up to twelve months.
12. Newhouse, R. et al (2011) Another interesting study, and very recent too. Liked that they included 'functional status' as an outcome, though it is nebulous what that means specifically. Study does not mention sample size or length of the studies that it reviews.
13. Office of Technology Assessment. (1986) Study is 28 years old - healthcare was different back then.
14. Ohman-Strickland, P.A., Orzano, A.J., Hudson, S.V., Solberg, L.I., DiCiccio-Bloom, B., O’Malley, D., et al. (2008) Only examines management of diabetes.
15. Prescott, P.A. & Driscoll, L. (1980) Study is 34 years old.
16. Roblin, D.W., Becker, R., Adams, E.K., Howard, D. H., & Roberts, M.H. (2004) Only examines patient satisfaction.
17. Sacket, D.L., Spitzer, W. O., Gent, M., & Roberts, M. (1974) First study I've seen that includes mortality as a measure. However, this study is 40 years old.
18. Safriet, B. J. (1992) Study is 22 years old, and only studies 'NP productivity, patient satisfaction, and prescribing, and data on nurse midwife practice' Each of those is not relevant, except maybe prescribing, but it doesn't go into detail about what that means.
19. Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, M., Gent, M., Kergin, D.J., Hacket, B.D., & Olynich, A. (1974) Probably the most promising study I've seen so far in favor of NPs, but it is 40 years old.
The problems that I continue to see in all of these studies are as follows:
1. Small sample size
2. Short duration of study
3. Outcomes measured are not really significant when determining ability to perform care independently.
4. From what I can tell, the studies do not control for NPs that practice under the oversight of a physician.
In order to truly conclude that NPs are functionally equal to physicians, we would need to complete a randomized, blinded (to a reasonable extent) series of case reports that follow patients for a significant period of time and observe key outcome markers, such as mortality, years of life after diagnosis, development of significant comorbidities, and physical or mental disability resultant from delayed treatment secondary to missed diagnosis, as well as cost.
Before you ask, this is why I do not believe patient satisfaction is a good measure of outcome:
You never did answer then why doesn't the AMA come out with their own studies showing superiority of physician training?
The data nor those studies are flawed. The beliefs that some physicians have in their own superiority is the only flawed subject in the debate over whether APNs/NPs should be able to provide independent care.
I can't speak for the AMA, but I would venture a guess that they haven't published any studies because physicians aren't the ones that are attempting to encroach on a scope of practice that has historically only belonged to another profession. Complicating this issue is the fact that a scientific study that would have real predictive power would be very expensive to conduct, and there aren't many people willing to do it.
The pro-nurse lobby is very quick to brandish their mantra that this is only for the patient's benefit, and that they're only seeking to expand their scope of practice for the good of the patient. While I don't think they're being disingenuous about their motivations, any physician that attempted to prove a slight inferiority of nurses would quickly be branded one of a number of things, such as: They're only in it for the money, they just want control of nurses, this is just a turf war and a matter of pride... The list goes on.
You mentioned that nurses use the same texts and references when they need to look up something as physicians? That's great! I love that you go to the best medical texts there are. Why can't you take the same exams physicians do, then?
I don't think chronic conditions are the issue. Once a problem has been identified, NPs can definitely manage the patient. I think where the physicians would stand out is with diagnosis of obscure disorders that many people won't see often. For example, one psychiatrist I know just told me the other day about a couple of patients that presented with pheochromocytoma, which appeared to be panic disorder. He said that he had only ever seen two cases of this in his entire career, and the only thing that differentiated them from his other panic patients was their prodigious diaphoresis. These are the kind of cases that a physician is more likely to catch.
I believe we just disagree on what is the best solution to that.
I had to respond to the pheo example. Was the patient fat too? I wonder if urine cats are the lowest yield diagnostic tests performed or not. Were those two patients seen by MDs or NPs.
So what is your solution to increasing access to primary care and spending more time with patients that doesn't include NPs or PAs?
I had to respond to the pheo example. Was the patient fat too? I wonder if urine cats are the lowest yield diagnostic tests performed or not. Were those two patients seen by MDs or NPs.
So what is your solution to increasing access to primary care and spending more time with patients that doesn't include NPs or PAs?
Sorry, I don't know the specifics of the cases he mentioned; I just brought them up to illustrate how rarely a practitioner may see some of these presentations.
I don't pretend to have all the answers, but I think we can all agree that we need more healthcare providers. I think the simplest solution is simply that we need to have more physicians, but the obvious problem with that is the cost. There likely aren't even enough medical school seats to produce all of the doctors that we need, and that's not even speaking of the problem that is the freeze in government funding for residency slots, which is the true gateway to practicing medicine.
I think that nurses are very valuable contributors to healthcare, and I believe that a nurse that has been practicing as an NP for 20 years is probably going to be just as capable as a physician. It would be wonderful to take advantage of the wealth of capable NPs in the country that are currently restricted from practice, but I don't think that the NP curriculum prepares them to practice medicine. I support the idea of NPs being able to practice independently if they're able to pass the same licensing exams as medical students. Someone previously in the thread mentioned that there is no proof that these exams guarantee a competent physician, and I absolutely agree. The exams are not perfect, and in fact they are far from it. However, they are the best standardized measure that we have. If you have a better way to test if medical students have learned the necessary concepts, then I would be interested in hearing about it. Why do these exams test the things they do? Because the NBME, which has produced the majority of the nation's physicians for most of its history, and also represents the highest level of medical education in the world, has deemed that these are the subjects a person licensed to practice medicine ought to know. If nurses are able to take and pass these exams with similar results, then I would conclude that medical education here in the US is what needs to change. Perhaps nursing has found a better way to do it? If NPs can demonstrate that they have the same amount of knowledge, then by all means we should change the way we do things.
Side note, a personal rant of mine: I can't stand it when nurses say that they absolutely don't want to be a doctor and that's why they became a nurse. They just want to practice to the full extent of their education. If you want to be an NP, diagnose illness, and prescribe medication, you're practicing medicine. That is what doctors do. If you are a nurse but those are the things you want to do, then you want to be a doctor.
Sorry, I don't know the specifics of the cases he mentioned; I just brought them up to illustrate how rarely a practitioner may see some of these presentations.
I don't pretend to have all the answers, but I think we can all agree that we need more healthcare providers. I think the simplest solution is simply that we need to have more physicians, but the obvious problem with that is the cost. There likely aren't even enough medical school seats to produce all of the doctors that we need, and that's not even speaking of the problem that is the freeze in government funding for residency slots, which is the true gateway to practicing medicine.
I think that nurses are very valuable contributors to healthcare, and I believe that a nurse that has been practicing as an NP for 20 years is probably going to be just as capable as a physician. It would be wonderful to take advantage of the wealth of capable NPs in the country that are currently restricted from practice, but I don't think that the NP curriculum prepares them to practice medicine. I support the idea of NPs being able to practice independently if they're able to pass the same licensing exams as medical students. Someone previously in the thread mentioned that there is no proof that these exams guarantee a competent physician, and I absolutely agree. The exams are not perfect, and in fact they are far from it. However, they are the best standardized measure that we have. If you have a better way to test if medical students have learned the necessary concepts, then I would be interested in hearing about it. Why do these exams test the things they do? Because the NBME, which has produced the majority of the nation's physicians for most of its history, and also represents the highest level of medical education in the world, has deemed that these are the subjects a person licensed to practice medicine ought to know. If nurses are able to take and pass these exams with similar results, then I would conclude that medical education here in the US is what needs to change. Perhaps nursing has found a better way to do it? If NPs can demonstrate that they have the same amount of knowledge, then by all means we should change the way we do things.
Side note, a personal rant of mine: I can't stand it when nurses say that they absolutely don't want to be a doctor and that's why they became a nurse. They just want to practice to the full extent of their education. If you want to be an NP, diagnose illness, and prescribe medication, you're practicing medicine. That is what doctors do. If you are a nurse but those are the things you want to do, then you want to be a doctor.
The incidence if pheo is somewhere between 0.8 and 1.6 out of 100,000 person years (that difference is d/t 59% being dx'd PM). That doesn't paint a good dx hx for MDs or NPs. This is also a dx that is going to be seen by most providers once or less in a career. I happened to be lucky enough to see one while in training, and the presentation had 1/3 of the classic triad and was normotensive. How many have you seen? Because I saw one does that make me more likely than a physician that's has seen none to make the dx?
Just because nurses are educated under a different model and take a different exam doesn't make them inferior. The research proves this. You talked in a previous post about this being a new era in healthcare and that old studies are outdated yet you are holding to the fact that tradition has shown the USMLE exams to be the baseline for patient care despite the evidence.
I've enjoyed the part about NPs spending more time with their patients. Especially when the NPs are able to do that in a primary care setting because the MDs are working 4 times as hard so that they can keep the lights on in the place. It's as if NPs don't realize that FM docs are limited in their time with patients from without, not within. FM docs don't hate their patients, they aren't choosing to spend less time with them, they are forced by the same bureaucratic nonsense that is giving you guys power. Big hint, big gov. givith and big gov. taketh away. You've made your bed, though.
Keep up your fight for autonomy, you'll quickly learn why there really is only 10-15m per patients in the budget, and heck, with those lower reimbursements rates, you might even be able to half that.
I can't speak for the AMA, but I would venture a guess that they haven't published any studies because physicians aren't the ones that are attempting to encroach on a scope of practice that has historically only belonged to another profession. Complicating this issue is the fact that a scientific study that would have real predictive power would be very expensive to conduct, and there aren't many people willing to do it.
The pro-nurse lobby is very quick to brandish their mantra that this is only for the patient's benefit, and that they're only seeking to expand their scope of practice for the good of the patient. While I don't think they're being disingenuous about their motivations, any physician that attempted to prove a slight inferiority of nurses would quickly be branded one of a number of things, such as: They're only in it for the money, they just want control of nurses, this is just a turf war and a matter of pride... The list goes on.
You mentioned that nurses use the same texts and references when they need to look up something as physicians? That's great! I love that you go to the best medical texts there are. Why can't you take the same exams physicians do, then?
Physicians groups have been espousing the inferiority of nurses for decades/100+ years in the case of CRNAs. There is no doubt that any physician group that can and could prove any slight inferiority of APNs would do it at the slightest opportunity. The ASA comes to mind when I say this.
Why do APNs need to take the USMLE? Does the USMLE pass rates guarantee lower mortality rates and/or better outcomes for patients? I am pretty sure that the AMA and every other American medical society would not allow NPs to take the USMLE 3 anyways just from the responses on the trial DNP exam from years ago. Medicine decries nurse doctorate exam being touted as equal to physician testing - amednews.com
I have always stated the same things: The APN battle for independence is about money and egos versus the desire to practice to the highest level of training and autonomy. It has nothing to do with patient safety which has been shown multiple times to be a nonissue. This issue goes back to the early 1900s even before the advent of NPs, and the exact same arguments are still being used (minus the ignorant USMLE argument).
So if NPs could take and pass the USMLE 3 you are saying these NPs should all be given instant ability to independently practice based soley on the USMLE exam???
I've enjoyed the part about NPs spending more time with their patients. Especially when the NPs are able to do that in a primary care setting because the MDs are working 4 times as hard so that they can keep the lights on in the place. It's as if NPs don't realize that FM docs are limited in their time with patients from without, not within. FM docs don't hate their patients, they aren't choosing to spend less time with them, they are forced by the same bureaucratic nonsense that is giving you guys power. Big hint, big gov. givith and big gov. taketh away. You've made your bed, though.
Keep up your fight for autonomy though, you'll quickly learn why there really is only 10-15m per patients in the budget, and heck with those lower reimbursements rates, you might even be able to half that.
This is the product of your touted medical education? I would sincerely hope most physicians would be embarrassed by this post.
Physicians groups have been espousing the inferiority of nurses for decades/100+ years in the case of CRNAs. There is no doubt that any physician group that can and could prove any slight inferiority of APNs would do it at the slightest opportunity. The ASA comes to mind when I say this.
It's as though you have no experience in the real world. In any occupation when someone with a lower degree of experience or education claims that they can do the job of someone with a higher degree of education or experience usually the later is quick to point out the flaws in such reasoning. Namely, the former is inferior and in this case, they are unfortunately unable to see why or how they are inferior.
Why do APNs need to take the USMLE? Does the USMLE pass rates guarantee lower mortality rates and/or better outcomes for patients? I am pretty sure that the AMA and every other American medical society would not allow NPs to take the USMLE 3 anyways just from the responses on the trial DNP exam from years ago. Medicine decries nurse doctorate exam being touted as equal to physician testing - amednews.com
The multi-step USMLE board exams are the standard to practice medicine in this country. Just like taking a driving exam is the standard to drive a car. If you can't read the signs, you shouldn't have a license to drive.
Your example fails to support your claim. You sited a study showing that physicians are pointing out the obvious differences and inadequacies of the bogus step 3 type exam NPs take. Contrary to your non-point, Physicians would love to see you guys take a real step 3. It's the easiest of the boards and most NPs would be crushed.
I have always stated the same things: The APN battle for independence is about money and egos versus the desire to practice to the highest level of training and autonomy. It has nothing to do with patient safety which has been shown multiple times to be a nonissue. This issue goes back to the early 1900s even before the advent of NPs, and the exact same arguments are still being used (minus the ignorant USMLE argument).
Money and egos? Yep, RNs want to become NPs for money and to stroke their egos. You've never been more right then you are right now.
I'm not sure you're clear on the definition of "ignorant". The only person who is lacking information in the argument are those who have never taken the exam. Try harder.
So if NPs could take and pass the USMLE 3 you are saying these NPs should all be given instant ability to independently practice based soley on the USMLE exam???
No, it's just one of the many laughable points in the ever increasing claims to equivalency of NPs. "You can't even pass our easiest exam, how do you expect to do our jobs?"
The incidence if pheo is somewhere between 0.8 and 1.6 out of 100,000 person years (that difference is d/t 59% being dx'd PM). That doesn't paint a good dx hx for MDs or NPs. This is also a dx that is going to be seen by most providers once or less in a career. I happened to be lucky enough to see one while in training, and the presentation had 1/3 of the classic triad and was normotensive. How many have you seen? Because I saw one does that make me more likely than a physician that's has seen none to make the dx?
Just because nurses are educated under a different model and take a different exam doesn't make them inferior. The research proves this. You talked in a previous post about this being a new era in healthcare and that old studies are outdated yet you are holding to the fact that tradition has shown the USMLE exams to be the baseline for patient care despite the evidence.
So
Before I misunderstand you, are you saying that you would have otherwise never known about pheo if you hadn't seen it during training?
You're right, the virtue of one's education does not automatically mean they are inferior to another. However, I think the sheer length of nursing education as compared to medical education, as well as the lack of standardization among NP programs, does mean they are not as prepared as physicians to practice medicine.
Again, the research does not 'prove' this. The only research I've seen cited so far proves that nurses are as competent as physicians at managing chronic conditions.
Physicians groups have been espousing the inferiority of nurses for decades/100+ years in the case of CRNAs. There is no doubt that any physician group that can and could prove any slight inferiority of APNs would do it at the slightest opportunity. The ASA comes to mind when I say this.
Why do APNs need to take the USMLE? Does the USMLE pass rates guarantee lower mortality rates and/or better outcomes for patients? I am pretty sure that the AMA and every other American medical society would not allow NPs to take the USMLE 3 anyways just from the responses on the trial DNP exam from years ago. Medicine decries nurse doctorate exam being touted as equal to physician testing - amednews.com
I have always stated the same things: The APN battle for independence is about money and egos versus the desire to practice to the highest level of training and autonomy. It has nothing to do with patient safety which has been shown multiple times to be a nonissue. This issue goes back to the early 1900s even before the advent of NPs, and the exact same arguments are still being used (minus the ignorant USMLE argument).
So if NPs could take and pass the USMLE 3 you are saying these NPs should all be given instant ability to independently practice based soley on the USMLE exam???
Medicine has a long history which has been blemished by a paternalistic model of medicine, where many physicians seemed to be of the belief that they were gods to their patients, and those around them. I think the majority of medical education today teaches students the values and benefits of nurses.
The USMLE is the standardized evaluation of medical students, for which a passing grade is required for a medical license. The people who fail this exam are not deemed capable of practicing medicine. This is a judgment that is agreed upon by every governing body of medicine in the country, including the government. From a brief skim of the article you posted, it looks like the uproar is because the NP test is different from the step 3 that residents take, and omits key parts of the exam.
I agree with you, the battle for independence does seem to be about money and egos. From the attitudes of many militant nurses I have personally dealt with, the goal seems to be to increase their scope of practice so they can make more money, without having to pay a physician to review charts. They can also 'shove it' to physicians who used to boss them around. I've seen this attitude on this very forum more than once. There are absolutely physicians that are guilty of this as well - reducing this battle to a turf war.
'Patient safety' has not been shown multiple times to be a non-issue. Again, the studies you cite prove that nurses are equally capable of managing chronic conditions. It is a logical fallacy to conclude from those data that therefore nurses are equally competent to practice medicine.
Finally, I'm saying if nurses can pass all the steps of the USMLE, Step 1, 2 and 3, then yes, they should be able to practice medicine. Physicians are subject to the same standards.
arg110
9 Posts
I agree with you - neither of those sound like good options. While it is my personal opinion and a matter for another debate entirely, I think that the 'work' some physicians do to review charts is garbage. It's a quick way to grab cash and not really do any work. It defeats the purpose of having a more expansive education; if a physician doesn't actually see the patient, how is he or she supposed to notice the rare disease at all? At the same time, I do realize there is a shortage of healthcare providers and the physicians here in the US would not be able to manage it alone.
Agreed completely about the financial part. The relationship between NPs and physicians was initially started to allow physicians to 'see' more patients, and thus increase their billables from insurance. I'm not a fan of that policy, but it speaks to the greater issue, which is the way health care is reimbursed - quantity, not quality.
I don't think chronic conditions are the issue. Once a problem has been identified, NPs can definitely manage the patient. I think where the physicians would stand out is with diagnosis of obscure disorders that many people won't see often. For example, one psychiatrist I know just told me the other day about a couple of patients that presented with pheochromocytoma, which appeared to be panic disorder. He said that he had only ever seen two cases of this in his entire career, and the only thing that differentiated them from his other panic patients was their prodigious diaphoresis. These are the kind of cases that a physician is more likely to catch.
I would agree with that.
Like I said, managing previously diagnosed conditions (or diagnosing common presentations) is not a weakness of NPs. In fact, I would say that if a patient comes to clinic for the sole reason of a checkup for their chronic condition, they most likely don't need to see a physician. New sick visits are something about which I would be more wary.
Some are funded by drug companies themselves, like I mentioned, but a big chunk of them are funded by the NIH.
Agreed. I'm sure most physicians would love to be able to spend more time with their patients, but hospitals push them to go as quickly as possible, and billing in private practice pushes them in the same direction.
I agree with you. Seeing more patients each day leaves less time for each patient, and will lead to missed diagnoses. It's a problem, in my opinion.
There are a lot of problems in healthcare today, but I don't think overeducated physicians are one of them. I think the bigger bills are more likely due to physicians that are more interested in money and performing procedures for which they can bill insurance, even if the procedures aren't necessary. Someone earlier in this thread mentioned a hip replacement for someone with end stage dementia - a perfect example of something I would deem completely unnecessary, and something done simply to get the physician money. This practice needs to be halted.
http://www.ruralmedicaleducation.org/basichealthaccess/Why_NP_Primary_Care_Solution.htm
This says 30-35% are still in primary care. I didn't read very far, though.
A dermatologist that has been in practice for 2 years couldn't provide quality IM care - they weren't trained in that specialty. They would most likely provide care on a similar level to a second year resident, which is where they were at the end of their general training as an intern. Who knows, maybe I'm selling them short.
Agreed. I believe we just disagree on what is the best solution to that.