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. Once the flashlight starts to shed light on this, let's see how the public feels.
also, does no one think this will create a two tiered system where the haves go to physicians and the have nots with no choice go to NP clinics?
I think online NP schools are in the same category as not requiring medical students to goto classes. It is funny thing sharing a class with medical students when they outnumber your APN class by 5 to 1 yet the APN class still has more people in attendance in every class. This apparently also holds true for clinical rotations where no one even assures that the medical students actually do anything during their rotations. I had one medical student that sat in the break room during her entire anesthesia rotation!
I don't think it will create a two tiered system mainly because physician groups will make sure that physicians are always covered by the same insurance. What I do foresee happening is that since the medical school system is relatively inflexible with market demands d/t funding of residency training is that NPs will easily outnumber FP physicians in almost every market. The patients that want to see physicians are going to have to wait longer and longer with more people becoming insured, especially if they are dead set against seeing NPs or PAs.
oh come on. I don't know why you guys even care about residents so much. We are physicians because we got the degree, but we are required to train (aka do a grueling residency where we have no life and get paid diddly) before we are unleashed on the public. I don't think anyone would argue the education from medical school alone is enough before you treat patients, which is exactly why MDs are so skeptical of APNs graduating from a program and being allowed to treat. Med school gives you the information, residency teaches you how to apply it in reality, not on paper.
i know you know this
Just for clarification: Medical students earn their Doctorate (M.D. or D.O. in the U.S.) after completing medical/DO school. They are usually considered physicians at that time or when they pass the correlating USMLE. I have heard different accounts on when they are actually considered physicians.
Anyone that goes through a U.S. medical school education has my respect for the work and education that they received. It is unfortunate that most physicians do not feel that way about any other healthcare provider's education when it is compared to theirs. Which has been apparently evident in every conversation with a physician for the last 16+ years.
Although, I have noticed that newer physicians educated in the last 10 years or so attitudes are getting mildly better though, so maybe there is hope on the horizon for some physician perspectives and attitudes.
Absolutely. As evidenced by the influx of baby doctors and med students rushing over here to get a bite of the apple.
As evidenced by physicians worrying about the loss of revenue when they can no longer charge for signing a chart or worrying if a layperson thinks if their healthcare can be provided just as good by an NP as a physician.
And as by evidenced by APNs increasing their scope and getting more and more of the pie. Both sides are protecting their interests, no one is innocent of this.
Both sides are protecting their interests. One wants to maintain the status quo (unless it suits them to change it) and the other side wants to use research to continue to evolve their practices, and for the laws to correlate to what many have already been doing for long periods of time already.
This isn't a patient care issue at all, except for the fact APN independence will increase access to care with no decreases in patient safety.
Both sides are protecting their interests. One wants to maintain the status quo (unless it suits them to change it) and the other side wants to use research to continue to evolve their practices, and for the laws to correlate to what many have already been doing for long periods of time already.
This isn't a patient care issue at all, except for the fact APN independence will increase access to care with no decreases in patient safety.
I'm growing frustrated with the fact that you do not seem to read anything. It doesn't seem like you've actually read any of the studies you so readily cite, nor does it seem like you're fond of actually reading the comments made by the people who disagree with you.
You posted an article (published by a nursing organization) that listed numerous studies in support of nursing independence. I literally addressed every study in there, and then you just dismiss me. You say that I can't just say studies are 'too old/too short', yet that is exactly what you have done concerning the 1999 article that the NYTimes author cited. I point out that some studies are too short because 2 years isn't enough time to see all of the significant problems that develop from poor management. I literally gave you a study (with a sample size of over 50,000) that pointed out why patient satisfaction is not a good measure of outcome. I also pointed out that many of these studies equate the ability to manage blood pressure (or other similar parameters) with being a good clinician. It seems to me that you think the entire practice of medicine just boils down to the ability to manage a patient's numbers. Is that what you're saying? Because I think that practicing medicine is much more than managing a patient's blood pressure or blood sugar.
I challenge you to examine the data and make your own conclusions regarding what the data reveals. If you take the time to read these studies, you'll find that the authors gather data on outcomes that I have mentioned, like BP, and then conclude that nurses can provide equal care. If the claim were that nurses are able to manage chronic HTN as well as physicians, then I would agree. But that's not what they're claiming. How about YOU examine the data and YOU make a conclusion. I would be shocked if you actually think that practicing medicine does NOT include outcomes like mortality or misdiagnosis.
You repeatedly state that there is no scientific study that 'proves' that the USMLE ensures competent physicians. I'm not aware of any studies about this, because it would be a ridiculous subject about which to create a study. There are no 'studies' that prove that the NP exam results in a competent nurse. Why do nurses need to take a licensing exam? There are no scientific studies that prove that a high school education creates better doctors. Why do we go to high school? There are no scientific studies that prove that doctors even need to go to school. Why don't we just put all our medical textbooks online and then say that anyone with access to the internet can be a doctor? We all have access to the same information, so why does it matter how we learn it?
The USMLE is in place to ensure that students are learning the material. This material has been determined by hundreds of years of medical practice to be what physicians ought to know. You do not need a 'scientific study' in this case.
In this case, you are repeatedly citing the same studies that do not 'prove' what you claim, and then asserting the presence of bad studies as superior to the lack of studies that prove otherwise. There are no scientific studies that unicorns don't exist. Does that therefore mean that they must exist because a few people claim they do?
I'm growing frustrated with the fact that you do not seem to read anything. It doesn't seem like you've actually read any of the studies you so readily cite, nor does it seem like you're fond of actually reading the comments made by the people who disagree with you.
You posted an article (published by a nursing organization) that listed numerous studies in support of nursing independence. I literally addressed every study in there, and then you just dismiss me. You say that I can't just say studies are 'too old/too short', yet that is exactly what you have done concerning the 1999 article that the NYTimes author cited. I point out that some studies are too short because 2 years isn't enough time to see all of the significant problems that develop from poor management. I literally gave you a study (with a sample size of over 50,000) that pointed out why patient satisfaction is not a good measure of outcome. I also pointed out that many of these studies equate the ability to manage blood pressure (or other similar parameters) with being a good clinician. It seems to me that you think the entire practice of medicine just boils down to the ability to manage a patient's numbers. Is that what you're saying? Because I think that practicing medicine is much more than managing a patient's blood pressure or blood sugar.
I challenge you to examine the data and make your own conclusions regarding what the data reveals. If you take the time to read these studies, you'll find that the authors gather data on outcomes that I have mentioned, like BP, and then conclude that nurses can provide equal care. If the claim were that nurses are able to manage chronic HTN as well as physicians, then I would agree. But that's not what they're claiming. How about YOU examine the data and YOU make a conclusion. I would be shocked if you actually think that practicing medicine does NOT include outcomes like mortality or misdiagnosis.
You repeatedly state that there is no scientific study that 'proves' that the USMLE ensures competent physicians. I'm not aware of any studies about this, because it would be a ridiculous subject about which to create a study. There are no 'studies' that prove that the NP exam results in a competent nurse. Why do nurses need to take a licensing exam? There are no scientific studies that prove that a high school education creates better doctors. Why do we go to high school? There are no scientific studies that prove that doctors even need to go to school. Why don't we just put all our medical textbooks online and then say that anyone with access to the internet can be a doctor? We all have access to the same information, so why does it matter how we learn it?
The USMLE is in place to ensure that students are learning the material. This material has been determined by hundreds of years of medical practice to be what physicians ought to know. You do not need a 'scientific study' in this case.
In this case, you are repeatedly citing the same studies that do not 'prove' what you claim, and then asserting the presence of bad studies as superior to the lack of studies that prove otherwise. There are no scientific studies that unicorns don't exist. Does that therefore mean that they must exist because a few people claim they do?
Your objections to the studies were misguided at best and idiotic at worst, and I did read your responses. I would have flunked every research literature critique assignment in graduate school, if I would have posted the senseless responses that you made. The only response to any study that might be credible that you made was about sample size, but since you completely disregarded the meta-analysis and literature reviews too then that point is also without merit.
There were studies that included mortality and morbidity you dismissed those too.
I am still waiting on you or anyone to provide any scientific study that refutes that NPs should not have independent practice, and until you can do that all you are doing is espousing personal opinion without any merit other than it is your opinion.
Arg I think the point is that there are NO legitimate (or otherwise) studies that show NP's provide a sub par standard of care (largely in primary care) vs medical doctors.
There is a single study from 15 years ago that purports to show NPs order more tests and actually end up costing close to what a doctor costs.
Yet there are what 50+ different studies posted just on this site from journals (many peer reviewed). Some were done back from 40+ years ago to 30 years ago to 20 to 10 all the way up to the last 3-5 years showing NPs level of care at minimum equal to physicians in certain areas of independent practice.
There were MDs/PhD's involved in many of these as well and some checked lab values/blood pressure averages and others reviewed re-admits and patient satisfaction rates.
Take any single or couple studies and you can say there scope was too narrow or patient satisfaction is inaccurate measuring stick or they looked at too short a time span but taking the evidence as a whole even when you include the NYT times mentioned research leads to an inevitable conclusion...
Your objections to the studies were misguided at best and idiotic at worst, and I did read your responses. I would have flunked every research literature critique assignment in graduate school, if I would have posted the senseless responses that you made. The only response to any study that might be credible that you made was about sample size, but since you completely disregarded the meta-analysis and literature reviews too then that point is also without merit.
There were studies that included mortality and morbidity you dismissed those too.
I am still waiting on you or anyone to provide any scientific study that refutes that NPs should not have independent practice, and until you can do that all you are doing is espousing personal opinion without any merit other than it is your opinion.
As long as I'm clear about this, you are of the opinion that managing blood pressure and blood sugar now equate to being totally competent to practice independently.
I did notice the studies that included mortality, and I noted that they were performed in 1974.
I don't think my objections to the studies were 'idiotic', I think you just don't like what I have to say. I've provided my reasons for refuting the conclusions of these studies, and the best response you have is that I'm 'idiotic' or 'senseless'. You said you wanted to debate the merits of ANY one of these studies - let's do it. Let's not just call me names because I disagree with you.
We can play the 'scientific study' game all day. I've yet to see any scientific studies that prove that these exams ensure competent nurses. I've yet to see any scientific studies that prove that nurses are equally capable as diagnosticians. I could go on...
Arg I think the point is that there are NO legitimate (or otherwise) studies that show NP's provide a sub par standard of care (largely in primary care) vs medical doctors.
There is a single study from 15 years ago that purports to show NPs order more tests and actually end up costing close to what a doctor costs.
Yet there are what 50+ different studies posted just on this site from journals (many peer reviewed). Some were done back from 40+ years ago to 30 years ago to 20 to 10 all the way up to the last 3-5 years showing NPs level of care at minimum equal to physicians in certain areas of independent practice.
There were MDs/PhD's involved in many of these as well and some checked lab values/blood pressure averages and others reviewed re-admits and patient satisfaction rates.
Take any single or couple studies and you can say there scope was too narrow or patient satisfaction is inaccurate measuring stick or they looked at too short a time span but taking the evidence as a whole even when you include the NYT times mentioned research leads to an inevitable conclusion...
You're absolutely right! My inevitable conclusion is that nurses can manage chronic HTN and DM as well as physicians, and they usually have comparable patient satisfaction scores while doing so.
Rob: I think the point that arg, Gluteus, MD2B are trying to make is that while those studies may have proven an equivalence in the practice of physicians and NPs in family practice, the items selected to compare their practice are misleading. They state that management of chronic conditions such as HTN, HLD, DM, COPD, et cetera should not be the measure of practice of family practitioners, but rather the ability of that practitioner to assess rarer etiologies and diagnose/refer out appropriately. Their argument includes that the practice of medicine allows for that ability to differentiate, and since nurse practitioners don't receive the same education in medicine as MDs and DOs, there is no true comparison between the two. They recommend that since the data produced by these studies proves a point that isn't sufficient for a comparison, NPs as primary care providers and family practitioners should at least be able to pass the last part (Step 3) of the same licensing exam as MDs and DOs (the USMLE).
I'm sorry for generalizing the argument of three users into one statement, but this thread has gotten long.
I think I can appreciate and respect the education and value MDs bring to the table while also completely supporting NP independence (my extreme preference would be residency's but that doesn't look likely anytime soon). Nurses aren't doctors, nor do they pretend to be. Which is why they don't and shouldn't take USMLE.
Also I understand what the point is in differences in education but all of these different objective and subject measures of the qualify of provider care is inadequate then what do we do from there? what are we to measure for evidence based research to guide the practice of healthcare in this country?
No one is disputing the differences in education but are we really saying the substantial extra $$ for MD is only to catch that rare once in a career condition? I find that to be extremely impractical in the real world of providing care to patients. ESPECIALLY when even doctors after years of being away from intensive med school prep can and do miss these zebra type conditions, should old MDs be forced to retake the USMLE to prove they can still catch these rare rare diseases we are overly concerned about? I think not... Not to mention that no one works in a vacuum, patients will be seen by MDs and NPs and everything in-between.
Seems to me based on the standard argument against that no amount of research or evidence would be enough for people who do not want NP's doing what they have already been doing for the last 50 years.
There is no un-ringing the NP bell to borrow a law phrase.
As long as I'm clear about this, you are of the opinion that managing blood pressure and blood sugar now equate to being totally competent to practice independently.
I did notice the studies that included mortality, and I noted that they were performed in 1974.
I don't think my objections to the studies were 'idiotic', I think you just don't like what I have to say. I've provided my reasons for refuting the conclusions of these studies, and the best response you have is that I'm 'idiotic' or 'senseless'. You said you wanted to debate the merits of ANY one of these studies - let's do it. Let's not just call me names because I disagree with you.
We can play the 'scientific study' game all day. I've yet to see any scientific studies that prove that these exams ensure competent nurses. I've yet to see any scientific studies that prove that nurses are equally capable as diagnosticians. I could go on...
You're absolutely right! My inevitable conclusion is that nurses can manage chronic HTN and DM as well as physicians, and they usually have comparable patient satisfaction scores while doing so.
Lets get this right you didn't like the morbidity and mortality outcomes of the studies I posted. You made no credible objections to the studies methodologies or other potential questionable points.
What studies are there to show that the USMLE makes competent physicians?
It is pretty sad when all someone can offer in a debate over the merits of NP independence versus thousands of studies showing NP are safe and effective providers.
Where is your scientific evidence to validate any of your points?
I think I can appreciate and respect the education and value MDs bring to the table while also completely supporting NP independence (my extreme preference would be residency's but that doesn't look likely anytime soon). Nurses aren't doctors, nor do they pretend to be. Which is why they don't and shouldn't take USMLE.
Also I understand what the point is in differences in education but all of these different objective and subject measures of the qualify of provider care is inadequate then what do we do from there? what are we to measure for evidence based research to guide the practice of healthcare in this country?
No one is disputing the differences in education but are we really saying the substantial extra $$ for MD is only to catch that rare once in a career condition? I find that to be extremely impractical in the real world of providing care to patients. ESPECIALLY when even doctors after years of being away from intensive med school prep can and do miss these zebra type conditions, should old MDs be forced to retake the USMLE to prove they can still catch these rare rare diseases we are overly concerned about? I think not... Not to mention that no one works in a vacuum, patients will be seen by MDs and NPs and everything in-between.
Seems to me based on the standard argument against that no amount of research or evidence would be enough for people who do not want NP's doing what they have already been doing for the last 50 years.
There is no un-ringing the NP bell to borrow a law phrase.
And it is too bad they can provide no scientific evidence at all to back up their arguments.
wtbcrna, MSN, DNP, CRNA
5,128 Posts
I think online NP schools are in the same category as not requiring medical students to goto classes. It is funny thing sharing a class with medical students when they outnumber your APN class by 5 to 1 yet the APN class still has more people in attendance in every class. This apparently also holds true for clinical rotations where no one even assures that the medical students actually do anything during their rotations. I had one medical student that sat in the break room during her entire anesthesia rotation!
I don't think it will create a two tiered system mainly because physician groups will make sure that physicians are always covered by the same insurance. What I do foresee happening is that since the medical school system is relatively inflexible with market demands d/t funding of residency training is that NPs will easily outnumber FP physicians in almost every market. The patients that want to see physicians are going to have to wait longer and longer with more people becoming insured, especially if they are dead set against seeing NPs or PAs.