I just read this on the Times' website. I'm a certified nurse-midwife, not an NP, but I'm outraged by this offensive, ill-researched, flat out inaccurate Op/Ed from an MD clearly worried about protecting his turf.
Advanced practice nurses are the wave of the future, and doctors like this guy need to learn to adapt or die. Sorry you're worried about your giant salary being threatened by a more cost-effective but equally competent set of providers, but our system is not currently sustainable. APRNs are the answer to the critical shortages of primary care and low-risk obstetrical providers.
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.
NPs have been independent here in NM for a long time. And some of the things you mention have been issues at some point. It has taken many years for us to iron out the issues. In my local community, it was only a few years ago that the CNMs got the right to dictate and sign their own notes in L&D. This after practicing there for many, many years.
So, I agree that there will be roadblocks thrown up to those who go independent in the early years in states that are just now gaining their independence. However, I don't see that as a reason to not push forward with this effort. Why wait? That's not an excuse to put off attempts to gain independence. It just means gaining independence isn't the final step, it's actually an early step, but a very important, critical one.
Many years later, the vast majority of the providers in my community work very well together. Many don't know or care what title one has, they just want the opportunity to help their patients or help yours. It's about helping people and just as importantly it's about the business. Everyone has to make a living! If the independent (and hopefully the non-independent NPs) fight back by sending their referrals to other, equally or more competent specialists whenever possible, well, then simple economics will cause the specialists to open up over time.
We had a new specialist come to town. Very talented, smart guy. Also very much of an abrasive jerk to each and every provider in town. He ****** off the NPs, PAs, MDs, DOs. He ****** off the providers in the ER, those in private practice, everywhere. I'm sure he was very competent, and some of the cases we sent his way early on, he did a very good technical job of treating those patients. However, after a while it wasn't worth it. Unless it was a life threatening issue, we sent the patients to another specialists in the town two hours away instead. It ended up costing our hospital some business, but it only lasted a few months before he was run out of town. Specialists need generalists too!
So, I would suggest that we strive for independence in all 50 states. Then if we are having other issues, which we will, we can determine how they need to be dealt with. Many will resolve themselves, some will require legislative issues, but by then we will have even more evidence that proves our case. Yes it will take time and persistence, but it is obtainable, and now is the time.
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.
The opposite situation is also worth contemplating. I am finishing FNP school in California and work with some NP for whom "MD supervision" and "physician collaboration" mean an MD stopping in every three months to have dinner and sign off a certain percentage of charts. She basically hires him to do this. So, how many "supervised" NPs are actually, effectively, working independently?
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
The opposite situation is also worth contemplating. I am finishing FNP school in California and work with some NP for whom "MD supervision" and "physician collaboration" mean an MD stopping in every three months to have dinner and sign off a certain percentage of charts. She basically hires him to do this. So, how many "supervised" NPs are actually, effectively, working independently?
Good point! just because an NP lives in a state that requires collaboration or supervision does not always mean that a true oversight exists as purported by the physician camp. There are so many FQHC sites here even in San Francisco where the NP's are already seeing patients on their own and the collaborating physician is merely a signature on a document.
I also don't buy the whole argument that primary care medicine has so many gray areas that NP's will miss on zebras and exotic presentations that have a wide differential diagnosis. I respect the training of physicians and they do have a broad understanding of various physiologies.
Where I work, patient one liners are not your usual 65 year old with controlled HTN and DM2...it would be the 45 year old with HTN on multiple antihypertensive meds complicated by ESRD with a history of CTD on steroids presenting with ground-glass opacities on chest CT scan of unclear etiology. But these patients are already being seen by multiple specialists so I don't see why NP's can't look after their primary care.
However, I agree that NP educational preparation is certainly a separate but related issue that must be addressed.
I'm in a state that requires collaboration. That means I pick 5 charts for my collaborating MD to look at and he assesses my level of care. I've scored 100% so far and he agrees with all my charts.
I have never, ever had a specialist reject my referral. I refer a lot for complex issues and utilize PT/OT more than I think most other outpatient providers do and I always get very respectful notes from specialists I've referred to or from the PTs seeing my patients. I did a bunch of specialty rotations as part of my FNP program and NPs were always a part of the practice and treated well.
In fact, one of my NP preceptors was considered THE expert for diabetes at her office. There were two MDs that had done endo fellowships that consulted HER for what they should do in terms of managing a patient's diabetes, and the hospitalist service at the hospital is having her implement new dosing for insulin based on carbs and replacing the sliding scale model.
The one study that was mentioned in the piece was written 15 years ago! If one of my students cited a 15 year old study, I would tell them to find more recent information.
I also work in a very narrow state, by definition. I think Florida has one of the most rigid supervisory requirements in the country.
But...
I work independently, without any issues at all.
An example:
Let's say I work up a 75 year old female patient with no known CAD who needs a hip replacement. I do echo and stress test preoperatively, and give her a moderate risk based on the findings. Wait, where is the physician in this? He has to meet and greet her on establishment to our office. After testing I put the clearance form with the results on his desk for his review. He signs it.
She has post-operative complication of atrial fibrillation with RVR and congestive heart failure despite being placed on BB for the surgery. I get the consult, log in from the office. The EKG shows atrial fibrillation and ST segment depression that is probably related to rate, but little else. I suspect fluid overload and anemia. I mention this to my covering physician. "OK" is the answer. I order diltiazem gtt, furosemide, BMP, CBC, BNP, CXR, and a Trop. I get there to find the trop neg, she is now anemic with a 3 gm drop in hgb, and BNP that is 388. The diltiazem has converted her back to sinus, and she has diuresed 1200 ml. She is breathing pretty well.
The physician was very much involved. Twice. It didn't hinder my care of the patient at all.
But being connected to this group makes for good collaboration, no roadblocks, and the ability to spread out office costs. We do pretty well.
I really don't see the argument for the "push for independence". While I agree that many NP's may be able to practice independently, I am not sure that those of us who are supervised find it much of a hindrance.
Automotive RN: 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.
I have to disagree. I know MANY patients who follow their NP just as they do a MD who moves.
I have frequently found that when someone is discussing an issue they look at it from their standpoint. For example automotiveRN67 said she didn't understand the need for the push for independence. I live in the Tampa Bay area. There are tons of physicians and NPs everywhere. Collaboration is not an issue. However, in some parts of the country it is an issue. There are approximately 1/3 of all counties in Texas that do not have a physician provider. However, due to their restrictive practice requirements, NPs cannot set up shop there. So the patients are left without care. There are parts of every state that are considered rural or underserved. That is one reason to "push for independence."
Just wanted to remind people to look outside their own box when considered issues.
zmansc, ASN, RN
867 Posts
NPs have been independent here in NM for a long time. And some of the things you mention have been issues at some point. It has taken many years for us to iron out the issues. In my local community, it was only a few years ago that the CNMs got the right to dictate and sign their own notes in L&D. This after practicing there for many, many years.
So, I agree that there will be roadblocks thrown up to those who go independent in the early years in states that are just now gaining their independence. However, I don't see that as a reason to not push forward with this effort. Why wait? That's not an excuse to put off attempts to gain independence. It just means gaining independence isn't the final step, it's actually an early step, but a very important, critical one.
Many years later, the vast majority of the providers in my community work very well together. Many don't know or care what title one has, they just want the opportunity to help their patients or help yours. It's about helping people and just as importantly it's about the business. Everyone has to make a living! If the independent (and hopefully the non-independent NPs) fight back by sending their referrals to other, equally or more competent specialists whenever possible, well, then simple economics will cause the specialists to open up over time.
We had a new specialist come to town. Very talented, smart guy. Also very much of an abrasive jerk to each and every provider in town. He ****** off the NPs, PAs, MDs, DOs. He ****** off the providers in the ER, those in private practice, everywhere. I'm sure he was very competent, and some of the cases we sent his way early on, he did a very good technical job of treating those patients. However, after a while it wasn't worth it. Unless it was a life threatening issue, we sent the patients to another specialists in the town two hours away instead. It ended up costing our hospital some business, but it only lasted a few months before he was run out of town. Specialists need generalists too!
So, I would suggest that we strive for independence in all 50 states. Then if we are having other issues, which we will, we can determine how they need to be dealt with. Many will resolve themselves, some will require legislative issues, but by then we will have even more evidence that proves our case. Yes it will take time and persistence, but it is obtainable, and now is the time.