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?
This is the product of your touted medical education? I would sincerely hope most physicians would be embarrassed by this post.
Solid point, a medical education is definitely about the economics of running a small practice and the bureaucratic head aches imposed by the government. We take at least two semesters in each, some of us become specialists in either one of these.
This is the product of your touted nursing education? I would sincerely hope most nurses would be embarrassed by your lack of a real rebuttal.
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:
This is just idiotic to respond to. You discount meta-analysis from Cochorane databases/literature reviews/other meta-analyses, state that nursing home care is easy (how many times have you actually provided care for nursing home patients on a continual basis?), the studies are too old/too small, and/or you don't like the patient measured outcomes. Yet, you cannot provide one scientific article to support that NPs should not be given independence.
This is why physicians are losing the battle for APN independence when all physicians can give are opinions and provide absolutely no scientific evidence to support their own arguments against APN independence. All the while providing unsubstantial arguments on pre-existing studies.
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.
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.
Again, can you provide any scientific evidence support your views?
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I guess you forgot the 3-year minimum residency...
It seems like you are saying that without a three year residency a person can not be a physican. I know that the residents I work with consider themselves to be phsyicans, yet they have not completed all three (or more) years of residency.
SO what is the cut off for physican / non-physican? If my residents are not physicans, despite holding a license to practice medicine (usually as PGY 2) what are they?
It seems like you are saying that without a three year residency a person can not be a physican. I know that the residents I work with consider themselves to be phsyicans, yet they have not completed all three (or more) years of residency.
SO what is the cut off for physican / non-physican? If my residents are not physicans, despite holding a license to practice medicine (usually as PGY 2) what are they?
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.
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.
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.
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?"
I have been a nurse for 16 years. I have been an independent CRNA for approximately the last 5 of those years. Just because someone has a higher degree and took more classes in x subject does not automatically mean they provide a higher level of care, if that was true then every MD/PhD would automatically be better at patient care than every other plain MD/DO.
You assume that NPs would be "crushed" by the USLME, but where is your proof? A one-time sample of nurses taking a knock off exam of the USLME that you have already discounted.
Oh yeah, NPs want independence for the great money (where are you getting that one) and it is real ego boost to be able to only want to practice to the fullest of your training. Since NPs have already been shown to provide as good or better care than physicians shouldn't we be arguing why aren't physicians showing they are at least equal to NPs and start taking one of the NP certification exams? I bet physicians would be "crushed" when taking the NP certification exam.
No matter what study is done or test NPs/APNs take some physicians will always downplay NPs ability to practice safely and independently. Now whose ego is overinflated?
By the way you goto love the sudden influx of SDN trolls on here.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
You can't be serious right now.
The point was made that one can be a physician after three years. You commented that the three year residency must have been forgotten. It seemed to me that you are saying one can not be a physican without a three year residency. Not adding up for me.
It seems like you are saying that without a three year residency a person can not be a physican. I know that the residents I work with consider themselves to be phsyicans, yet they have not completed all three (or more) years of residency.
SO what is the cut off for physican / non-physican? If my residents are not physicans, despite holding a license to practice medicine (usually as PGY 2) what are they?
Wow!.. They are physicians in training. It is impossible to get a job with a year internship even you can be a fully licensed physician in some states. These residents are just physicians by name. Do you really believe a nurse that graduated with a BSN and go straight to University of Phoenix to get a NP degree will function on the same level as a physician who graduates from the worst med school in the country and did a 3-year residency in FM? If you believe that, there is no need for me to argue with you...
I have been a nurse for 16 years. I have been an independent CRNA for approximately the last 5 of those years. Just because someone has a higher degree and took more classes in x subject does not automatically mean they provide a higher level of care, if that was true then every MD/PhD would automatically be better at patient care than every other plain MD/DO.
It's as if you don't realize that a Ph.D and an MD/DO are completely different degrees. Do you know the difference? I'm going to assume you'll do some quick wikipedia reading and sort this out. After you do that, you'll realize that a Ph.D in say...biochemistry, has very little in common with a doctorate in Medicine. One would not, nor should not, expect that a PH.D would make their clinical medicine knowledge or skill stronger. There are no "clinical medicine" classes required for a Ph.D. One has nothing to do with the other.
So no.
You assume that NPs would be "crushed" by the USLME, but where is your proof? A one-time sample of nurses taking a knock off exam of the USLME that you have already discounted.
You're lucky I've discounted it, did you even read that article? Only 50% of NPs passed a weak, abbreviated, watered down *read EASIER* version of Step 3. You sure you really want to build your castle on that foundation??
If someone says they can paint the Mona Lisa but struggles to paint a straight line, I don't usually need scientific evidence to make a conclusion. Nor do most people, you might want to rethink that strategy.
Oh yeah, NPs want independence for the great money (where are you getting that one) and it is real ego boost to be able to only want to practice to the fullest of your training. Since NPs have already been shown to provide as good or better care than physicians shouldn't we be arguing why aren't physicians showing they are at least equal to NPs and start taking one of the NP certification exams? I bet physicians would be "crushed" when taking the NP certification exam.
I'm getting it from the same place you're getting "it's about money and egos" in fact, I took that phrase without justification straight off of your previous post. Man, so much for your all "scientific evidence" approach, amIright?!
"to the fullest of their training". I like an Orwellian phrase as much as the next person, but that's some pretty empty rhetoric. I can train a high school drop out to design internal combustion engines...should he be allow to do it? Think harder.
Yes, physicians who passed Step 1 (the hardest), Step 2 (medium soft hard), Step 3 (time for viagra?), would be crushed by an abbreviated easier version of Step 3. Is there a sarcasm emoticon that I can use here? Honestly, does this make sense to you?
No matter what study is done or test NPs/APNs take some physicians will always downplay NPs ability to practice safely and independently. Now whose ego is overinflated?
By the way you goto love the sudden influx of SDN trolls on here.
You want to practice medicine? Go to medical school. If you can get in.
HotHamWater
36 Posts
Solid point, a medical education is definitely about the economics of running a small practice and the bureaucratic head aches imposed by the government. We take at least two semesters in each, some of us become specialists in either one of these.
This is the product of your touted nursing education? I would sincerely hope most nurses would be embarrassed by your lack of a real rebuttal.