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?
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.
because in healthcare the scope of the physican > scope of the NP? EMTs learn how to do many of the same things that paramedics can do and their scope continues to expland, but paramedics have higher scope of practice and more authority because of their education and training. Can the EMT suddenly be like well no I refuse to work under you, paramedic, I've decided that I now know enough to be just as good as you for most things... So thanks but I'm not going to work under you. You don't have any proof that an EMT is any worse than a paramedic...
I just feel like some people are arguing to have it both ways. You want to say NPs are NOT doctors and we do not need to know as much as they know because we are doing a completely separate job... but that new job looks exactly like the job they currently do.
Why should a doctor be the head of the medical team? really? I understand nursing and medicine are different professions but come on. Nursing wasn't designed to be the head of the medical team.
Not a completely separate job. There are tons of overlapping areas in scopes of practice. But they ARE different.
Just because something use to be the sole scope for a physician doesn't mean it is divine law that it stay that way forever.
Things change and already have changed. There is no turning all the NPs in the country back into basically CNS's or "physician extenders".
Nurses may not have been designed that way but advanced nurse practitioners were and are certainly capable of being leaders in health care.
Except APNs were actually designed to be physician extenders not physician replacements. When the APN programs were originally created it was to help with the access gap and work in collaboration with MDs, with MDs being the lead due to their expertise. NPs in most places in the country are physician extenders. It's not an offense, it's the role they play on the team.
I'm capable of being president, it doesn't mean I'm qualified or should be doing it
Specializes in Pediatrics, High-Risk L&D, Antepartum, L.
Except APNs were actually designed to be physician extenders not physician replacements. When the APN programs were originally created it was to help with the access gap and work in collaboration with MDs, with MDs being the lead due to their expertise. NPs in most places in the country are physician extenders. It's not an offense, it's the role they play on the team.
I'm capable of being president, it doesn't mean I'm qualified or should be doing it
They were designed to be physician extenders? Where is that statement of fact written? Just wondering.
because in healthcare the scope of the physican > scope of the NP? EMTs learn how to do many of the same things that paramedics can do and their scope continues to expland, but paramedics have higher scope of practice and more authority because of their education and training. Can the EMT suddenly be like well no I refuse to work under you, paramedic, I've decided that I now know enough to be just as good as you for most things... So thanks but I'm not going to work under you. You don't have any proof that an EMT is any worse than a paramedic...
I just feel like some people are arguing to have it both ways. You want to say NPs are NOT doctors and we do not need to know as much as they know because we are doing a completely separate job... but that new job looks exactly like the job they currently do.
Why should a doctor be the head of the medical team? really? I understand nursing and medicine are different professions but come on. Nursing wasn't designed to be the head of the medical team.
EMTs don't work under paramedics, both EMTs and paramedics work "under" the EMS medical director. There is no paramedic checking the EMTs chart and charging him $$$$ for the privilege.
I sure the GI-NP does colonoscopy too...Lol. You can not be serious!
Well now that you bring it up:
Horton, K., Reffel, A., Rosen, K., & Farraye, F. A. (2001). Training of nurse practitioners and physician assistants to perform screening flexible sigmoidoscopy. Journal of the American Academy of Nurse Practitioners, 13(10), 455-459.
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!
Which one or any of those courses have been proven to reduce morbidity and mortality increase physicians ability to diagnosis/treat diseases? There is a point when a lot of education is great, but does not add value in the day to day work in primary care, if the simple amount of education made on a better provider then MD/PhDs would be the top level providers based on that logic.
Again do you have any scientific evidence to back up any of your opinions or are you just going to stick with the one with the most education must be the best provider argument.?
because in healthcare the scope of the physican > scope of the NP? EMTs learn how to do many of the same things that paramedics can do and their scope continues to expland, but paramedics have higher scope of practice and more authority because of their education and training. Can the EMT suddenly be like well no I refuse to work under you, paramedic, I've decided that I now know enough to be just as good as you for most things... So thanks but I'm not going to work under you. You don't have any proof that an EMT is any worse than a paramedic...
I just feel like some people are arguing to have it both ways. You want to say NPs are NOT doctors and we do not need to know as much as they know because we are doing a completely separate job... but that new job looks exactly like the job they currently do.
Why should a doctor be the head of the medical team? really? I understand nursing and medicine are different professions but come on. Nursing wasn't designed to be the head of the medical team.
Nurses have been leading the care of patients for centuries sometimes alone and in more recent times with the physician dictating the overall treatment plan. APNs/CRNAs have been around for 150 years working independently for that entire time. Nursing also used to be a male dominated profession. Florence Nightingale changed a lot of what nursing was to become today or the at least through the early 1900s, but that is fairly recent in the historical perspective of nurses.
I would still like to know what class or classes that medical students take that qualifies and/or teaches to lead healthcare. Nurses are required from undergraduate to graduate level courses to take leadership and management courses are taught group dynamics, healthcare policy, and this continues on through NP training with advanced training on providing/managing care of patient as a provider.
Physicians can make great healthcare providers, but they often stink at managing healthcare teams/supervising. Anyone that has been a nurse for anytime at all can give countless stories of dealing with physicians that were awful at communicating/didn't listen, and caused all sorts of pt associated problems d/t their lack of management/leadership skills.
This fight over what is medicine and what is nursing (podiatry/dentistry/midwifery versus medicine also) has been going on longer than any of us have been alive. Frank u South, 175 Ky. 416, 194 S.W. 375(1917) (This is probably the earliest known cases that determined that when nurses provide care it is an act of nursing and when a physician provides care it is an act of medicine even if that care is exactly the same).
http://www.aana.com/advocacy/stategovernmentaffairs/Documents/feb%201998.pdf This sums up some of the legal battles and decisions (obviously slanted towards nurse anesthesia, but still relevant since these cases are where the precedences were set for continuing to allow APNs to practice at their fullest capabilities).
It is sad that the exact same arguments have been used by physicians for over 100 years.
Except APNs were actually designed to be physician extenders not physician replacements. When the APN programs were originally created it was to help with the access gap and work in collaboration with MDs, with MDs being the lead due to their expertise. NPs in most places in the country are physician extenders. It's not an offense, it's the role they play on the team.
I'm capable of being president, it doesn't mean I'm qualified or should be doing it
Show me where APNs were designed to be physician extenders. That is a an outright myth someone has told you.
CRNAs were the first APNs. CRNAs were implemented to keep the residents from killing surgical patients from lack of attention while providing anesthesia. Elsevier
The APN being a physician extender is a myth. When both types of primary care providers are seeing the exact same patients and same number of patients in a clinic that is two providers working together. One is not extending the services of another one. They are both doing the same work.
Also, when you use the term APNs that encompasses all APNs not just NPs. CRNAs have been around for 150+ years in U.S. before these terms were even invented and before there was even more than a handful of physicians providing anesthesia. CRNAs for one have never been physician extenders/mid-level providers or any other term that physician groups chose to come up with. All of these titles are meant to try and show that APNs are somehow less than physicians which is not true. APNs differ in their training compare to physicians, but all APNs have shown that they can provide equal care in our chosen specialities compared to our physician colleagues.
Specializes in Pediatrics, High-Risk L&D, Antepartum, L.
Show me where APNs were designed to be physician extenders. That is a an outright myth someone has told you.
CRNAs were the first APNs. CRNAs were implemented to keep the residents from killing surgical patients from lack of attention while providing anesthesia. Elsevier
The APN being a physician extender is a myth. When both types of primary care providers are seeing the exact same patients and same number of patients in a clinic that is two providers working together. One is not extending the services of another one. They are both doing the same work.
Also, when you use the term APNs that encompasses all APNs not just NPs. CRNAs have been around for 150+ years in U.S. before these terms were even invented and before there was even more than a handful of physicians providing anesthesia. CRNAs for one have never been physician extenders/mid-level providers or any other term that physician groups chose to come up with. All of these titles are meant to try and show that APNs are somehow less than physicians which is not true. APNs differ in their training compare to physicians, but all APNs have shown that they can provide equal care in our chosen specialities compared to our physician colleagues.
I have asked several times for proof about statements. I have almost no replies to my comments. I give up. We are supposed to bow down because they said so while any and every study we show is flawed.
The good news...they don't matter in the long run. I think this is chest pounding by those who aren't even in the field. Let's face it...nurses with years of experience working in the field with opinions versus some med students. We have been out there working with doctors and NPs and these are people who truly are just starting their path.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I don't think anyone wants people to go without care.
I don't suspect anyone of wanting people to go without care.
T
hat 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.
I know what you are talking about. I have observed to practice of "health workers" in rural India. They are regular people who get taught some basic hygiene practices and how to screen for common diseases. Despite their lack of training they have made a huge difference in the health of the rural people.
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.
I disagree. While it is true that many, or even most NPs will head to where the pay and lifestyle are, a percentage WILL fill those criticaly underseved areas. I was watching "Deadliest Catch" the other day and noted that the clinic in Dutch Harbor was staffed with an NP who had a video link to a physician in Anchorage.
Speaking of NPs in specialties. I have never observed an NP working independantly in a speciality. All of them I know work with physicians of that specialiety. I don't think we will see NPs doing neuro or CV surgery, but will see them doing pre-op work ups and following them post op all while working in close colaboration with physicians. In thos case they function as physican extenders. The only area of independant practice for NPs I am aware of is primary care. There are of course CRNAs all over the country doing independant practice but that is different. That is a case of physicians invading a nursing practice. The first MDAs learned from CRNAs.
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.
I mostly agree with you. It is obvious that NP will follow physicians to where the lifestyle and compensation is. But some / many of them ARE and WILL serve in the most underserved areas. A rural area that can compensate a provier at, say $110K / year is unlikely to recruit a physician, but is very likely to be able to recruit an NP.
PS: that story about OCPs is crazy! And sad
Sad but true. At this moment, while there are providers willing to prescribe OCs, the only retail pharmacy in the area will not dispence them, again on religious grounds. Women must drive more than an hour to get OCs dispenced.
If you have noticed an inconsistantcy between how I describe where I live and where I work it is because I have two jobs and comute 3 hours each way to work. Where I live has nothing in common with where I work.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Omg.
A doctor with only a Bachelor's degree is scary.
I can't imagine why that would be. The MBBS is not the same as a bachelors degree in the USA. Their medical school seems to be the equilevent of US medical schools. There are many, many physicians practicing in the USA with the MBBS degree.
MD2B
38 Posts
because in healthcare the scope of the physican > scope of the NP? EMTs learn how to do many of the same things that paramedics can do and their scope continues to expland, but paramedics have higher scope of practice and more authority because of their education and training. Can the EMT suddenly be like well no I refuse to work under you, paramedic, I've decided that I now know enough to be just as good as you for most things... So thanks but I'm not going to work under you. You don't have any proof that an EMT is any worse than a paramedic...
I just feel like some people are arguing to have it both ways. You want to say NPs are NOT doctors and we do not need to know as much as they know because we are doing a completely separate job... but that new job looks exactly like the job they currently do.
Why should a doctor be the head of the medical team? really? I understand nursing and medicine are different professions but come on. Nursing wasn't designed to be the head of the medical team.