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?
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
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 a physician shortage excuse will fly. I used to work in San Diego and every hospital i worked in was lavishly staffed with physicians. As a nurse I could hardly take a step without having to avoid yet another doctor. Seems to me that places like San Diego could do with a few less physicians and places like where I live could do with a few more. I don't blame them at all for wanting to live in San Diego and make more money rather than live in rural Wisconsin and make less money. However to claim a shortage when very nice places to live have tons of doctors and less desirable places have few or none doesn't make sence to me.
PMFB-RN you mention Alaska, so I thought I would post this link. Home Page Alaska is unique in that we have Community Health Aides and Dental Health Aides. They both serve as providers in rural Alaska providing care for the native population. It puts a real twist on who should be providing care, educational levels of different types of providers, and outcomes.
I don't think a physician shortage excuse will fly. I used to work in San Diego and every hospital i worked in was lavishly staffed with physicians. As a nurse I could hardly take a step without having to avoid yet another doctor. Seems to me that places like San Diego could do with a few less physicians and places like where I live could do with a few more. I don't blame them at all for wanting to live in San Diego and make more money rather than live in rural Wisconsin and make less money. However to claim a shortage when very nice places to live have tons of doctors and less desirable places have few or none doesn't make sence to me.
Every APN role was developed directly related to some kind patient care need. In the case of NPs it was the shortage of physicians in rural areas which is still a problem today. Not many people want to work in rural care areas. The more rural the harder it is to get people to live and work in those areas.
"The final advanced practice role to develop was the NP role, which began in the 1960s and 1970s in direct response to a shortage of primary care physicians in underserved areas, especially rural areas." http://www.jpedhc.org/article/S0891-5245(08)00323-4/fulltext
I guess my perspective is different. I have recieved very top notch emergency care from providers who never set foot in a college. I am talking about 18-D special forces medics who took care of me all the times I was wounded while in the army......
I am far less impressed with academic degrees and much more impressed with level of skill, regaurdless of how they came to have their
As a side-bar, I am also an Army vet (as well as being old enough to be the mother of every medical student on this forum) and what PMFB-RN alludes to is an overlooked aspect of NP and PA training. These positions showed up first, in the late 70's, in the military, to facilitate care in a cost-effective manner at more troop-level settings than a hospital.
These EARLY NP and PA's were almost always highly experienced as RN's or Corpman/Medics. ONLY those with vast clinical expertise were sent to school for the "book-learning" and credentials. Most of these folks were AWESOME, with diagnostic and treatment skills that were off the charts. I would....and have....trusted this group with my life.
Fast forward to the 21st century and on-line *ahem* universities. Now we are looking at people with little or no time in the trenches, and there lies the rub. Health care is more complicated and certainly more mired in red-tape, and yet there is NO substitute for clinical experience, no matter how long or short the academics.
I agree with IrishIzRN, when I was 18 and profoundly anemic, I went to my pediatrician and was not even able to sit up on the exam table because I was so fatigued, and the dr. was CLUELESS as to what could be wrong with me. Did not suggest that I even go to the hospital, did not do blood tests. I got chest pain that night, went to the ED, where the triage nurse saw me, stood up immediately yelling OMG! because I was deathly pale and knew exactly what was wrong with me, given my history. And she was just a RN. So, if a prudent healthcare provider, MD or APRN, feels something is beyond them, wouldnt they refer you to a specialist? I am a nurse and I see a nurse practitioner for my primary care, and I know that if what she is telling me doesnt seem right or doesnt answer my questions, I would get a 2nd opinion. Patients also have to take some of the responsibility of their own health and do this if they feel they need to.
Oh, and, what if an APRN has a doctorate which they are pushing for now, not just the MSN. Would you address her "Dr. So and So"? Other PhDs not in the medcial profession get to call themselves "Dr.".
I think the appropriate phraseology is Dr. Xyz I will be your nurse practitioner for today or whatever.
It may depend more on hospital politics... Some places only allow medical doctors to be called doctor in that specific setting and it makes some sense since there are more and more PhD/respiratory/nursing doctorates in the hospital today.
Though if psychologists with "only" a PhD is referred to as Doctor than so should the nurse practitioner DNP.
I don't think a physician shortage excuse will fly. I used to work in San Diego and every hospital i worked in was lavishly staffed with physicians. As a nurse I could hardly take a step without having to avoid yet another doctor. Seems to me that places like San Diego could do with a few less physicians and places like where I live could do with a few more. I don't blame them at all for wanting to live in San Diego and make more money rather than live in rural Wisconsin and make less money. However to claim a shortage when very nice places to live have tons of doctors and less desirable places have few or none doesn't make sence to me.
You can make the same argument for nursing. There are significantly more nurses/APNs in metro areas. People tend to work/live 1) where they are from 2) where they have the most opportunities. There are significantly more nurses than doctors, especially since it takes so long to produce a doctor.
I think the appropriate phraseology is Dr. Xyz I will be your nurse practitioner for today or whatever.
It may depend more on hospital politics... Some places only allow medical doctors to be called doctor in that specific setting and it makes some sense since there are more and more PhD/respiratory/nursing doctorates in the hospital today.
Though if psychologists with "only" a PhD is referred to as Doctor than so should the nurse practitioner DNP.
I have no problem calling anyone with a doctorate "Dr So and so." I get no ego boost by being called doctor, in fact I introduce myself as "Dr. MD2B but you can call me FirstName, but I'm laid back. I think it's just confusing for a patient since doctor has become synonymous with physician, especially in the clinical setting.
If you walk up to someone and say I'm a doctor, they don't assume PhD (unless you are in a college/academic setting).
Oh no I don't want to see how they did on a similar exam...same exam. Similar...not close enough for me actually.
Also, is there data showing that passing the exam means excellent provider? Oh right...there isn't because lots of crap doctors out there.
So similar exam and you believe the exam means excellent outcomes. Huh? How does that work for a legal defense? He passed the exam...so he's great! Yeah...no.
The DNP exam is a "watered-down" version of the USMLE Step 3 made by the NBME, genius.
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 was referring to hierarchy/chain of command on the team. I was an EMT so I understand the dynamics.
But if that analogy doesn't suit you, substitute for paralegal/lawyer... medical assistant/nurse... teacher's assistant/teacher.
My mom is a teacher's assistant, she never graduated from college. When her teacher is absent, rather than calling a substitute, they pay her the same wage as the substitute and she teaches the class. She's teaching the class this entire week. Can she do it? Sure, she's quite capable. Can the TAs then turn around and tell the principal we are just as good as the teacher (and work without them often) so we should be hired as teachers? Should we send TAs to the middle of the country to fill the teacher shortage? Would you let your kid go to that school or would you pay more to get a real teacher?
So those arguing independence shouldn't happen...can you show a study or something factual that proves bad outcomes? The nurses here have provided studies showing positive outcomes and all we get back is "that study is flawed" and "you seen educated enough". Show us proof that independent practice is bad for patients.
Yeah, studies funded by nursing lobbying groups who have a vested interest in the result. Yeah, no conflict of interest there.
PMFB-RN, RN
5,351 Posts
I don't think a physician shortage excuse will fly. I used to work in San Diego and every hospital i worked in was lavishly staffed with physicians. As a nurse I could hardly take a step without having to avoid yet another doctor. Seems to me that places like San Diego could do with a few less physicians and places like where I live could do with a few more. I don't blame them at all for wanting to live in San Diego and make more money rather than live in rural Wisconsin and make less money. However to claim a shortage when very nice places to live have tons of doctors and less desirable places have few or none doesn't make sence to me.