Offensive Op/Ed About NPs

chillnurse, BSN, RN, NP · Apr 30, 2014

At least the title is right. We aren't doctors. We just do the same thing with less education. Minus surgery and stuff of course. That actually does require mega training

Advanced Practice Columnist / Guide · Apr 30, 2014

I'm all about hearing opposing views and don't mind people expressing opinions that aren't compatible with my own. However, I do want to point out that the study Dr. Jauhar cited has many flaws and it's such a shame that a physician of his stature would usurp such a study to advance his agenda. The study he cited was conducted at a VA system where there was no way to even trace who ordered the expensive tests (US, CT, MRI) on the patients, only the fact that the patients were under the care of an NP for primary care. Also, the study did not adjust for severity of illness in the patient panel of the physicians and NP's so there is no clear explanation regarding the difference in the incidence of specialty referrals and hospital admissions.

The study can be read here: A Comparison of Resource Utilization in Nurse Practitioners and Physicians

automotiveRN67 · Apr 30, 2014

After reading this article, I am surprised....well maybe not surprised, that this blowhard (blow-hard) doesn't know the difference between education and expertise. I would never tell a physician my education is equal to theirs. It just isn't. Very few clinical hours, not as much classroom time.

But my experience is equal to theirs. After 25 years I know how to look for answers to questions that intrigue me. Why did my patient collapse and smash his face. The differential diagnosis list numbers close to 30. But quickly deciding which direction to search comes from years of listening carefully to the patient. Believe me when I say this. I see patients every day who have been "worked up" by physicians who were way off base. I wouldn't be critical of their work as a collective. This J-off should not be critical of ours, as a collective.

I am a believer in the two-tiered system. It is not cost effective for physicians to train for 6-10 years to learn the highest level of specialty, and then sit around reading stress tests or something. Physicians have a two-tier system also. This guy just hasn't thought of it. It is called ----wait for it ---- the referral. Primary care physicians who do not have specialty training ask for a consult for special issues. Working in a specialty practice, I am the one who sees their patient. I won't order a renal workup, I will ask for a nephrologist to consult. But I will decide between stress test, cardiac cath or home. All on my own. And I will justify that with years of experience.

He does make a point at the end that I agree with. I believe in the two-tier system. Actually, I believe in a three-tier system. I believe the most efficient healthcare system would be based on a mid-level tier, an internist tier, and a specialist tier. I think mid-level practitioners are well suited to be part of either physician-led team. I am not convinced the new law in New York, or any other state gives enough safety to that practice of medicine. While physicians have to pass the scrutiny of hard-ass attendings in a university environment, nurse practitioners can be licensed with very little oversight. I include myself in that statement.

Until our profession stops weakening our educational system, I believe he is right.

**LibraSunCNM, BSN, MSN, CNM** · Apr 30, 2014

Juan, that was one of my biggest issues. He was REALLY reaching if he calls that article even close to strong evidence supporting the need for physician oversight, which just made it all the more petty to me. I personally am convinced that the NYS law is safe, as similar laws have passed nationwide for NPs as well as CNMs, and no adverse effects on patient care have been noted (that I am aware of). I do not mind hearing other points of view either, but this wasn't a well reasoned argument, it was a low blow.

automotiveRN67 · May 1, 2014

Juan, that was one of my biggest issues. He was REALLY reaching if he calls that article even close to strong evidence supporting the need for physician oversight, which just made it all the more petty to me. I personally am convinced that the NYS law is safe, as similar laws have passed nationwide for NPs as well as CNMs, and no adverse effects on patient care have been noted (that I am aware of). I do not mind hearing other points of view either, but this wasn't a well reasoned argument, it was a low blow.

Sorry. I have to disagree with this. With no real minimum requirement for NP's starting an independent practice, I am afraid. Maybe, if a NP had 5 years experience that was verified by attestation, to fill in the lack of residency it would be safe. Maybe. But with schools churning out online degrees like mine. I am really afraid.

There are 3 reasons why NP's as independent practitioners is not a real-world idea.

1) Specialist physicians are unlikely to accept consults from NP's who are practicing independently. At least not with the current tensions. I sat in on a conversation today in the physician's lounge. This is the general consensus.

2) Patients may "talk the talk" when they rate their NP's well, but most will not follow an NP who separates from a group to start their own practice. When given the choice, physician or NP, they will choose the physician.

3) I know physicians right now who are closing their office because they can't afford the overhead. The two I know of this week, are taking salary jobs. An NP billing at 85% certainly won't make ends meet. Without being able to do advanced procedures (colonoscopies, heart cath, pacemaker, cysto) it isn't likely. And that privilege is very unlikely.

Options may be:

1) Hospital-supported general practice that has NP's, and accepts some of the lesser quality insurance plans. A physician would probably still be assigned and paid to have his/her name on the wall. This would be for risk-protection even if it was simply an administrative position

2) Medicaid clinics

3) Lack of malpractice insurance. I haven't read the law completely, but my insurance is cheap because I ride the back of the physicians. Insurance companies wouldn't have to grant insurance to NP's who are solo practice unless they were forced to. I am thinking the insurance companies and the AMA would make sure insurance is printed on an unobtanium certificate.

4) And what exactly is the issue anyway? I don't know a physician in the past 10 years who has popped out of medical school and started a solo practice. Most join a practice at salary, then transition to bonus plus, and finally partner. Costs and bills are too high. So where are all these wealthy NP's coming from, that have the ability to open an office when MD's cannot? Most come out of school broke, with less earning potential. No bank is going to front a loan to them.

I think it is all just rhetoric. Or at just plain BS.

**LibraSunCNM, BSN, MSN, CNM** · May 1, 2014

Sorry. I have to disagree with this. With no real minimum requirement for NP's starting an independent practice, I am afraid. Maybe, if a NP had 5 years experience that was verified by attestation, to fill in the lack of residency it would be safe. Maybe. But with schools churning out online degrees like mine. I am really afraid.
There are 3 reasons why NP's as independent practitioners is not a real-world idea.
1) Specialist physicians are unlikely to accept consults from NP's who are practicing independently. At least not with the current tensions. I sat in on a conversation today in the physician's lounge. This is the general consensus.
2) Patients may "talk the talk" when they rate their NP's well, but most will not follow an NP who separates from a group to start their own practice. When given the choice, physician or NP, they will choose the physician.
3) I know physicians right now who are closing their office because they can't afford the overhead. The two I know of this week, are taking salary jobs. An NP billing at 85% certainly won't make ends meet. Without being able to do advanced procedures (colonoscopies, heart cath, pacemaker, cysto) it isn't likely. And that privilege is very unlikely.
Options may be:
1) Hospital-supported general practice that has NP's, and accepts some of the lesser quality insurance plans. A physician would probably still be assigned and paid to have his/her name on the wall. This would be for risk-protection even if it was simply an administrative position
2) Medicaid clinics
3) Lack of malpractice insurance. I haven't read the law completely, but my insurance is cheap because I ride the back of the physicians. Insurance companies wouldn't have to grant insurance to NP's who are solo practice unless they were forced to. I am thinking the insurance companies and the AMA would make sure insurance is printed on an unobtanium certificate.
4) And what exactly is the issue anyway? I don't know a physician in the past 10 years who has popped out of medical school and started a solo practice. Most join a practice at salary, then transition to bonus plus, and finally partner. Costs and bills are too high. So where are all these wealthy NP's coming from, that have the ability to open an office when MD's cannot? Most come out of school broke, with less earning potential. No bank is going to front a loan to them.
I think it is all just rhetoric. Or at just plain BS.

But is IS a reality in 16 states now, not just rhetoric. So far, the sky hasn't fallen. And the law isn't necessarily just for NPs who want to start their own solo practice, NPs can still work in practices with physicians in those states. Independent practice doesn't mean there is no longer collaboration or referral.

I agree very much with you about online schools churning out diplomas, that scares me as well. Graduate nursing education could use a lot of improvement. But I don't see how having a written practice agreement with an MD really changes that.

allennp · May 1, 2014

Great conversation. I struggle with this issue. In my state which has independent practice for NP's I am aware of schools that push folks with a BS or a MS thru a RN program then two more yrs to sit for FNP boards, then they are out practicing? After 25 yrs in a lot of high acuity roles I carefully practice and feel fairly competent...carefully and humbly, though everyday I feel a imperfection in some way.

I am stunned to think they would consider they could practice alone, in reality they do not though. Ever talk to a medical student first yr intern? Same thing, it's just that in the NP world we do not have many residencies, most are just get a job in what you wish/want to do and learn working with a team.......

i think though it's mostly fear mongering in articles like this as reality is so much different.

a

mahaandai · May 1, 2014

No pun intended, these subject lines would be a fit for prestigious New York Times:

1. Lawn doctors are not doctors

2. Car M.D. are not real M.D.

3. Dr. OZ on tv is not a profitable m.d. since he prefers alternative medicines in health care

4. Witch doctors are witches and not doctors

5. Pharmacists are not doctors

6. Nurse Practitioners should wear scrubs with flowers and petals on them and only doctors deserve wearing white coats

Not sure when will this nonsense end

PMFB-RN, RN · May 1, 2014

Sorry. I have to disagree with this. With no real minimum requirement for NP's starting an independent practice, I am afraid. Maybe, if a NP had 5 years experience that was verified by attestation, to fill in the lack of residency it would be safe. Maybe. But with schools churning out online degrees like mine. I am really afraid.
There are 3 reasons why NP's as independent practitioners is not a real-world idea.
1) Specialist physicians are unlikely to accept consults from NP's who are practicing independently. At least not with the current tensions. I sat in on a conversation today in the physician's lounge. This is the general consensus.
2) Patients may "talk the talk" when they rate their NP's well, but most will not follow an NP who separates from a group to start their own practice. When given the choice, physician or NP, they will choose the physician.
3) I know physicians right now who are closing their office because they can't afford the overhead. The two I know of this week, are taking salary jobs. An NP billing at 85% certainly won't make ends meet. Without being able to do advanced procedures (colonoscopies, heart cath, pacemaker, cysto) it isn't likely. And that privilege is very unlikely.
Options may be:
1) Hospital-supported general practice that has NP's, and accepts some of the lesser quality insurance plans. A physician would probably still be assigned and paid to have his/her name on the wall. This would be for risk-protection even if it was simply an administrative position
2) Medicaid clinics
3) Lack of malpractice insurance. I haven't read the law completely, but my insurance is cheap because I ride the back of the physicians. Insurance companies wouldn't have to grant insurance to NP's who are solo practice unless they were forced to. I am thinking the insurance companies and the AMA would make sure insurance is printed on an unobtanium certificate.
4) And what exactly is the issue anyway? I don't know a physician in the past 10 years who has popped out of medical school and started a solo practice. Most join a practice at salary, then transition to bonus plus, and finally partner. Costs and bills are too high. So where are all these wealthy NP's coming from, that have the ability to open an office when MD's cannot? Most come out of school broke, with less earning potential. No bank is going to front a loan to them.
I think it is all just rhetoric. Or at just plain BS.

Since the issues you bring up are already non-issues in other states I assume that you mean that these issues would be specific to NY?

automotiveRN67 · May 1, 2014

I know that it is reality in 16 states. At least by law. I am not sure how many actually practice independently. In the real world. But removing the barrier of oversight, and decreasing the educational requirements at the same time opens up a huge concern.

As allennp states. Overconfidence seems to be the driving force, and unfortunately, it is ruffling the feathers of physicians. When I mention that I sat in on a conversation with physicians, who are all specialists, that was very similar to this topic, the consensus was that they would sandbag consults. Hospitalists would have to admit patients on an emergency basis, but they may "direct" patients to an internist when they are discharged. There is a lot of politics at play.

I would love to here from an NP who actually practices independently in one of the 16 states. Their insight would be most valuable in this conversation.

PMFB-RN, RN · May 1, 2014

We have several NPs who have admitting privages in my hospital. The usually round on them in the morning before they go to the clinic. They consult specialists, take call on their patients, pretty much exactly like the primary care physicians. I don't know how the physicians feel about it, I do know that when, for example an NP consults cardiology, the cardiology people come just like when they get any other consult.