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?
Rob: To address the first stanza of your post: I think the counterargument has been made that NPs in the position of primary care of family practice - by assessing, diagnosing, and prescribing medications - are practicing medicine, and are acting as physicians. Hence, they should be responsible for taking the requisite licensing exam for their presumed practice.
This is my perception of the argument that has taken place here so far. I hope it's accurate as there seems to have been a good deal of miscommunication too...
In the beginning of this thread I stated how I think this might be a good "pilot study" for NPs across the country to sort of "prove themselves" as equivalent, independent, autonomous primary care providers. A lot of the principles we in healthcare base our treatments and care on have been developed by evidence-based practice. There is a reason we don't practice certain nursing care anymore (e.g. saline instillation in trachs to mobilize secretions), and that's because research and the scientific process have proven that they produce poorer outcomes. My opinion is that, in the end, outcomes justify the means by which they're reached. If an outcome is proven by solid, ethical, evidence-based practice, how can it be controverted?
Of course I stated this not knowing that there are already numerous states where NPs are permitted to practice independently of MD or DO supervision, and that NY is just another one being added to the list. It seems there are a number of politicians who agree with the members of this board that NPs are capable of providing primary care independently.
TU RN: That is the heart of the issue isn't it? Some MDs are saying that by treating, diagnosing, and managing patient illness as they have been doing for the last 50 years nurse practitioners are practicing medicine without a license.
The fact is according to the only available evidence based research & the nations laws governing ALL medical professionals that APRN's are not practicing medicine, they are practicing advanced nursing. There is nothing written in stone from God saying ONLY an MD can care for or prescribe medication to a patient.
Scopes of practice change all the time and what was once the sole domain of the RN may now be shared by medical assistants/UAPs. What was once thought ONLY available to the medical doctor has now become an area of overlapping scope of practice.
That is not going to change.
The people and the law determines these things... Not NPs or MDs or any one healthcare professional.
I believe (my opinion only) that if the USMLE was so critical to providing safe patient care we would see a hint of that in the decades and dozens of studies evaluating objective care markers. But yet...
Maybe my experience is unique and I feel lucky but I have felt nothing but respected by my physician peers and often use them as a resource.
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.
Thank you TU RN! I think you summed up the arguments really well.
I would add that I don't think any physician can say a NP can't manage chronic conditions. NPs have been doing this for along time and doing it well -and it's supported by data that many of you have referenced. Like TU RN said, this is not the only job of a FP/PCP, it's a gross simplification. And the difference isn't just ability to catch zebras. let's be real we all can and will miss that at some point. I think that's important but it's kind of silly. It's the ability to diagnose, manage, and refer when appropriate. It's a way of thinking. Anyone can learn what to do and follow cookbook medicine. It's understanding the why - not just for mental fun but to understand how to spot a disease when it doesn't look like the textbook - is what is so fundamental. You learn that from medical school and mostly from residency training.
Part of the point is that the "collaborative agreement" is a joke. It doesn't do anything. NPs are practicing independently with some silly agreement that does nothing.
I don't see how anything changes except removing that sill agreement.
For the record, I think some collaborative agreement where some physician 100 miles away randomly looks at charts and just signs off is reckless and silly as well. I wouldn't support that either. I support true collaboration like I see in my city, which admittedly has a lot of physicians. Here a clinic might have 1-2 MDs and 4 NPs, all working side by side with the NP having their own pt panel and the MD there as back up while they see their own patients as well.
I would like to correct you a little bit. NPs already have independent practice in the more advanced and less backwards states. It's a done deal and has been for some time now. There is no change being talked about here.
I would also like to point out that the main reason this has been possible (in my opinion) is due to physician abandonment of large groups of people in need of heath care. I have already described how my little town was unable to attract a physician and that the people in the area have greatly diminished access to any sort of health care until an NP opened up shop. Is this NP a physician equivalent? No she isn't and doesn't claim to be. Are there a lot of people in my community with chronic conditions that would go either totally unmanaged, or very infrequently managed without having a local provider? I live here and can tell you the answer is absolutely yes. Does she manage them as well as a physician would? I don't really know but her management is a LOT better than none.
Until a few years ago a woman was unable to obtain a prescription for oral contraceptives or have an IUD placed without a very long drive. There used to be 4 physicians who practiced a few towns over where the hospital is (45 min drive in good weather) one was a surgeon and didn't see patients for that sort of thing, two of the FM guys refused to prescribe them at all to anyone on religious grounds, and the remaining one would only prescribe them to married women. Yes I am talking about this century. It wasn't until a NP began offering these services that the situation changed. Now 2 of the 4 are retired or gone and there are two physicians who will prescribe birth control.
While it is true that many NPs are in specialties, I am convinced that it is situations like I described above that made independent practice possible for NPs.
I'd disagree that physicians have completely abandoned certain areas, there aren't enough of them to go around so unfortunately the least desirable areas suffer the most. But I digress...
I don't think anyone wants people to go without care. That is a tragedy and we need to fill that gap any way we can. It's horrible that we have such an access problem that we would have to resort to leaving an NP out there to do it on his/her own without the proper support. However, in my mind, this should be similar to how we train health care workers in countries with little to no access to hospitals. You train lay people to do the basics and manage the community in the absence of proper support (I'm not comparing nurses/NPs to an average citizen, I'm saying the situation is similar). I think in that kind of situation it's appropriate, assuming the NP has the proper support to reach out to and has the proper competency.
In an idealistic world I would say YAY NPs are filling that gap in the middle of no where, but we all know that's not really going to happen. They will flock to the more desirable areas like we did because, like many on both sides have stated, it's about the money. NPs aren't fighting for this for the good of patient care. I have no doubts NPs will also fight for similar independence in specialties.
If you read the Wiki link I provided you would see that they are not equivelent at all. The bachelor of medicine is a professional degree. Who is making comparisons between a bachelors degree in the USA and the BMBS bachelors degrees in those countries?
I know many physicans who practice in the USA with a BMBS degree they earned in other countries, usually in 5 years of college after graduating from secondary school. I work in a teaching hospital with physicans trained in many different countries. Many of them are Americans who went to medical school abroad.
We see this with nursing degrees in the USA all the time. ADNs are often refered to as "two year RNs", when for the majority it actually takes 3-4 years to earn and ADN.
Nurses aren't doctors, nor do they pretend to be. Which is why they don't and shouldn't take USMLE.
I'd argue if their scope now has expanded to the same as family providers or PCPs they are functioning as doctors (whether it's pretending or not is not for me to judge). They should take the same licensing for the same function. It's a really easy exam and covers broad topics that are all covered by family practice. And it's only one exam we take. We also have to become board certified which is significantly more difficult.
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
I agree. It's not the heart of the argument. I'd like to think I didn't just spend $350k to be able to spot Lesch Nyhan Syndrome or be a guest on that TLC show about mystery illnesses.
should old MDs be forced to retake the USMLE to prove they can still catch these rare rare diseases we are overly concerned about?
Just for the record, they don't re-take usmle step 3 but they do have to be re-certified every few years, which yes includes knowing that random stuff. Sounds fun.
Specializes in Pediatrics, High-Risk L&D, Antepartum, L.
For the record, I think some collaborative agreement where some physician 100 miles away randomly looks at charts and just signs off is reckless and silly as well. I wouldn't support that either. I support true collaboration like I see in my city, which admittedly has a lot of physicians. Here a clinic might have 1-2 MDs and 4 NPs, all working side by side with the NP having their own pt panel and the MD there as back up while they see their own patients as well.
So you support true collaboration...that's fine. I think we should all collaborate. An MD shouldn't hesitate to collaborate with another MD or even an NP and an NP should be willing to do the same. The collaborative agreement does nothing more than have a doctor sign off on some charts. That's it. That agreement doesn't make sure people talk. Doctors don't always talk to each other...so what makes anyone think that the NPs should have a piece of paper saying it...when that paper is relatively meaningless to every NP I know. I know a CNM who works out of her own office. She has a collaborative physician who works elsewhere. He does what he needs to do. She contacts him if she needs to contact him. She doesn't make the contact because of the piece of paper. She basically practices independently and they just do what they need to do to make that piece of paper legal...the MD and the CNM. That piece of paper holds no meaning except to create a picture where the MD is almost boss. You guys aren't nurses. Why should a doctor over seeing an NP? We are different professions. We do similar things but they are different. I don't see why the MD gets to control the NP...not the same profession.
That broad education is an issue though. You have family practice physicians thinking they can treat a mom with gestation diabetes...and I've seen them not know when to let go. Every single mom who came onto our labor floor who had FP as their group and had anything slightly wrong (such as diabetic) meant for a disaster. The nurses would cringe when we would see FP listed as the doc...because we knew what path we were headed down. We had a doctor who thought he knew all he needed to know about the pregnant woman and delivering when he knew very little. There is something to be said for the very specialized education from the very beginning. When you compare a family practice MD to a specialized NP...I'm going with the NP. I see an MD for my primary care provider. He isn't my PCP because he's an MD. He's my PCP because we fell onto him and really do love him. I would just as quickly go to an FNP for my care. I would never in a million years see my family practice MD for anything specialized. My kids have an MD for a ped. Their GI specialist...NP. And an FYI...an MD walked in the room one day at a GI appointment and commented that someday she will know as much as our NP knows and talked about how the NP is the one to see.
Please don't discount the importance of specializing and the downfall to that broad education of the family MD.
I sure the GI-NP does colonoscopy too...Lol. You can not be serious!
Specializes in Pediatrics, High-Risk L&D, Antepartum, L.
I sure the GI-NP does colonoscopy too...Lol. You can not be serious!
Where did I say she did colonoscopies? I didn't. Ever. So I'm not sure what your point is or what is funny. When they need a test...there is a doctor who can do it. No biggie.
1. APNs school do have common curriculum they have to follow, and at the APN level nursing and medical school education becomes blurred. APNs learn and take many of the same subjects as physicians. Thee obvious differences, but the main difference is going to be in the residency portion of medical school. I think we can safely say you don't know what you don't know about NP training.
2. You are confusing undergraduate nursing with APN training and going back and forth. One of the first things you are taught in APN schools is that you are going to have to stop thinking like a regular undergraduate nurse. There is definitive proof that being a nurse for x amount of years before coming an APN helps, but there is also no proof that all those extra clinical rotations outside of a physician's chosen speciality in years 3&4 or their intern year helps make them better physicians in their chosen speciality either.
By the way I am sure a smart enough physician could learn to be a nurse (sounds kinda of condescending doesn't it).
The whole context of nurses are wanting to be physicians (which you really need to stop using doctor to describe physicians all the time because everyone from PT/ST/OT to pharmacy and nursing all have or beginning to get their doctorates and all work in the hospital settings, and these people are just as proud of their degrees as you are) is a falsehood. Nurses are wanting to practice as APNs with the autonomy and the level of education that they have been trained at. APNs have multitudes of studies that prove they can safely and effectively practice independently which no one has been able to provide any scientific evidence to refute. There is no benefit to "supervision" which is often only a way to increase a physician's income and has no benefit to the patients.
3. The study you are referring to has already been refuted about increased costs and NPs. I would say until you goto NP school then you don't know what you don't know. It works both ways.
USMLE do not prove competence. Please show me a study that says USLME=competence in practice. APNs already have their own licensing exams that have proven effective. They do not need to add another one just to prove physicians wrong. The USMLE is mute argument. There is no way that NPs would ever be allowed to take the USMLE for the fear of what would happen when they started passing them in high numbers. Exams show basic mastery over a subject nothing more and nothing less.
Again you are confusing undergraduate nursing with APN level education. The education at the APN level is more like medical education than nursing or medical establishments care to admit to.
I have talked to APNs that have made the switch, specifically a CRNA to an anesthesiologist, he said it wasn't worth it. Medical education is great, but it still doesn't empower you with super powers or make someone deity. There comes a lot of benefits with becoming a physician over being an APN and I am sure that has lots to do with former APNs espousing the greatness of becoming a physician.
Family Nurse Practitioner Exam Sample Questions Let's see how you do taking this test cold with no help from the internet. It is very small sample, but hey it should be relatively easy for anyone training in the primary care area.
I am sure APN take biochem, Genetics, Immunology etc... You don't even have to take general chemistry at the college level to get into NP school in my state. I have many friends attending NP school now... PLEASE!
They are already providing care to whole families in this capacity. They aren't looking to expand into anything except to remove a pointless piece of paper that costs them 10s of thousands a year for no more than what any colleague taking consults would provide. 17 states now (with NY) do not even require this piece of paper and yet patient care quality remains at the same level it has always been at.
Why if with their current education, experience, and licensing they provide (by every available clinical research study) safe and efficient care would they agree to switch to take exams that MDs specifically train to take to do the EXACT thing they are already doing.
MDs are already paid FAR above what NPs make in respect for the number of years and sacrifice they make in schooling.
I would actually agree with you MD2B if there was any indication the USMLE produced better or safer PCP providers. I would say absolutely this is important stuff where peoples lives are at stake and because this is not about turf wars NPs should be forced to take the USMLE to be safe providers.
But that isn't what the decades of objective evidence suggests.
TU RN, DNP, CRNA
461 Posts
Rob: To address the first stanza of your post: I think the counterargument has been made that NPs in the position of primary care of family practice - by assessing, diagnosing, and prescribing medications - are practicing medicine, and are acting as physicians. Hence, they should be responsible for taking the requisite licensing exam for their presumed practice.
This is my perception of the argument that has taken place here so far. I hope it's accurate as there seems to have been a good deal of miscommunication too...
In the beginning of this thread I stated how I think this might be a good "pilot study" for NPs across the country to sort of "prove themselves" as equivalent, independent, autonomous primary care providers. A lot of the principles we in healthcare base our treatments and care on have been developed by evidence-based practice. There is a reason we don't practice certain nursing care anymore (e.g. saline instillation in trachs to mobilize secretions), and that's because research and the scientific process have proven that they produce poorer outcomes. My opinion is that, in the end, outcomes justify the means by which they're reached. If an outcome is proven by solid, ethical, evidence-based practice, how can it be controverted?
Of course I stated this not knowing that there are already numerous states where NPs are permitted to practice independently of MD or DO supervision, and that NY is just another one being added to the list. It seems there are a number of politicians who agree with the members of this board that NPs are capable of providing primary care independently.