tobra99

Yes, the patient comes to the hospital for both nursing care as well as for the inpatient delivery of physician expertise/surgery. However, as a paid employee of the hospital, you deliver the "product" that the hospital is selling to its patients, and therefore the nurses are an expense they hospital must pay in order to deliver their product. If the hospital does not like your performance or if you do not comply with its policies, they can simply replace you with someone else who does. However, physicians, unless they are hospital employees, bring the patients to the hospital to which the hospital can sell its "product" (nursing care, facilities, OR equipment). Therefore, the nurses are not directly generating revenue for the hospital, even though they are providing a vital service that cannot be provided in an outpatient setting. They indirectly bring business to the hospital by providing quality nursing care, which improves the reputation of the hospital, making patients and physicians want to come there. Since physicians bear the role of direct primary revenue generators of the hospital, and the hospital administration/CEO knows the physician often times has a choice in which hospital to send their patients to, the administration will often do what it takes to keep the physicians happy, in order to maintain the flow of patients and revenue. I believe this is the basis for the preferential treatment of physicians at some hospitals. I would think this would less likely be the case at academic institutions or hospitals that employ their physicians. Therefore, I am a little surprised the OP notices this differential treatment at an academic center, unless it's a hospital affiliated with an academic center to which an academic group provides services where hospital needs the services more than the physicians need that hospital.

Just because your lounge is 2 floor away and you have patients on multiple floors doesn't mean the beverage policy should not be applied to physicians, if the policy was put in place for a patient safety issue. Moreover, I do not think the medical student is any more part of the physician team than a nursing student is part of the nursing team. Your 80 hours a week during the surgery rotation is part of your medical education, and if during your education you also help out by getting labs, then that is great but it doesn't entitle the medical student any rights to a computer more than any other staff. Conversely, if a nurse, charge or otherwise, prevents someone else from using "nursing designated" computers, I consider that an impediment to patient care. In the end it comes down to the greed of the original poster's hospital CEO. Hospital administrations realize that physicians are providing the expertise that brings in the patients, and (especially in private practice), physicians have the choice of which hospital they want to send their patients to in order to deliver that expertise. Last year, I realized I brought in millions in revenue to a hospital from my surgical volume as a surgeon, and I cost the hospital only the equipment I ask them to buy for me. There is no other worker at that hospital that brings in anything close to that amount except other surgeons. I can easily take my patients to the hospital down the street and make them millions of dollars richer instead. That realization alone by the CEO is what gets physicians the best parking spots, the upscale attending lounges, and the ability to drink beverages on rounds. The business and greed of healthcare is unfortunately what turns an ideal healthcare working environment where everyone is held to the same standards for the patient's sake, into one that bends over backwards for those that can most line the CEO's pockets.

I can definitely see my job (neurosurgeon) needing less and less skill in the foreseeable future with the advancement of technology. We are using stereotactic navigation that literally acts as a GPS device for the brain to take out brain tumors, robotics to put in spinal instrumentation, electrophysiologic monitors that can tell you in real time if a nerve is being touched the wrong way. When I think about how my forefathers in the profession performed surgery without these technologies, I can only imagine how much more skill, anatomical knowledge, and raw God-given talent it took to perform accurate neurosurgical procedures than required of neurosurgeons today. As these technologies continue to evolve and become more automated and autonomous, it will come to a point where quite unskilled workers will be able to perform neurosurgery, and eventually no humans will be needed at all. The high prestige and high priced education will really then be for the researchers and innovators, which are the driving force behind these technological advancements. The immense training that health care providers currently endure will really not be necessary to the degree that it required today. I graduated from a top 10 MD school and trained at one of the top hospitals in the country. I believe this realization that significantly less educated/skilled people will eventually be able to do my job can possibly make me and my "elite" education feel less "elite". I believe this reflects the plight of the MDs in general, as they may feel the exclusiveness of job they perform afforded to them by their elite education no longer seems so exclusive.

Unfortunately, there is still a stigma that exists in the MD world that DO's represents the weaker group of physicians, although this is probably not true. I remember comments reflecting that attitude among my classmates when I was in medical school. MDs often tend to define their intelligence and worth based on the extremely high admission standards to get into MD medical schools, which are the highest admission standards of any school in any profession. Because these admission standards are so high, students matriculating into MD schools are often the top students from the best universities in the country. Since they made the "cut", they believe they are the best of the best, and another body of professionals (DO/NP) who aim to do a similar job, but have lower admission standards, will be viewed as less qualified and less elite in their eyes. It is a tough stigma to break, because so much of the ego of the US trained MD is due to not only their exhaustive length of training but knowing that they had to be brightest of the brightest to even get in. DO's have shown time and time again that they can compete successfully in the MD arena with similar outcomes. NP's are on their way to showing this with the outcome data that is out there. I think it is somewhat heartbreaking for the MD's to realize that it doesn't take a valedictorian from an Ivy league university with perfect MCAT/SAT scores with a Rhodes scholar with 12 years of education/training to do their job after all. This degrades the illusion in their mind that being a doctor equates to having a prestige that is unobtainable for the common folk, and thus they will be resistant to all competing entities that claim to also be able to do their job (DO/NP), in order to protect that elitism. In the end however, market forces will trump over prestige, and the need for cost effective healthcare with good outcomes will drive the evolution of primary care to the NP arena. In another 100 years or so, I suspect even the NP will be supplanted by something else than can do their job even cheaper/more effective (artificial intelligence), but that is an entirely different topic of discussion and reflects the trend of humanity overall.

Yes, I agree with all your examples. They are example of good, astute nursing care. However, I don't think nurses exclusively hold the title of the "saviors" of physicians' butts. Aside from from the nurses, the radiologists, pharmacists, respiratory techs, office staff, etc save our butts on a routine basis. In addition, I think the physicians also frequently save the nurses' butts. As a neurosurgeon, I have countless times caught significant changes in neuro exams that were missed by the nurses. Many times have I found ventriculostomies or lumbar drains that were leveled or zeroed incorrectly, which if I don't catch myself, may lead to significant CSF overdrainage leading to intracranial hemorrhage or inaccurate ICP measurement. However, I don't hear many physicians exclaiming that they save the nurses' butts, not nearly as much as I hear how the nurses' saved the physician from catastrophe. It really shouldn't be about anyone's butts. The beauty of having multiple people involved in a patient's healthcare, each with their own training, skills, and scope of practice, is that it allows a system of checks and balances to minimize errors causing by any and all healthcare professionals. When I hear so much about how nurses pride themselves on saving the physician's butts, to me it somewhat implies that any given patient's care is centered around the physician and his/her decisions/actions, and that all other personell are just there to support the physician and catch their mistakes. I think if the nursing profession is trying to stand out as a separate but necessary aspect of health delivery, independant and fundamentally different from the physician, then the pride of nurses should not be on supporting and catching physician's mistakes, but instead on what they can offer independent of what the physician can offer.

I hear this a lot from the nursing community. What exactly do you mean when you say that you "saved the physician's butt"?

Crap! I had typed up a long, drawn out response to this, and then my message got deleted before I could click submit. I will try to re-type it when I get some motivation again.

I think I would agree with you that medical residents would also be quick to refer to subspecialists early. Anecdotally, I have worked in hospitals where the ER is primarily run by residents, and I do recall that the ER residents would consult a specialist for almost everything and anything. In the hospitals I work in now, there are no ER residency programs, and the ER attendings seem much more able to handle moderately complex issues without obtaining a consult. However, for true cost and outcome analysis, the comparison here needs to be between NPs and fully-trained primary care attending physicians, as residents are still just in training. I am a neurosurgeon who receives many referrals from both primary care physicians as well as NPs. I would estimate that 60-70% of the patients referred to me by primary care MD's actually have a neurosurgical issue. That rate seems to be signicantly lower for the patients referred to me by NPs, meaning more of those patients never needed formal evaluation by a neurosurgeon and would have done well with appropriate workup and conservative management by their primary care provider. Because I bill for the consultation for each patient even if they have no neurosurgical issue, that may result in a lot of costly but unnecessary visits to the neurosurgeon (but means more business for me :) ), where I would just end up ordering the diagnostic tests anyway. For those patients, diagnostic workup + unnecessary neurosurgical eval would cost signficantly more than diagnostic workup alone, regardless of who is ordering the diagnostic workup. Keep in mind that these numbers I am spitting out are just my estimates. I would have to go back to my records to see the actual numbers, but maybe it would be an interesting cost analysis for the future. Also I hope anyone reading these posts doesn't think I'm against the concept of NPs in anyway. I do think NPs are the future of primary care. I post here because I have been curious about the nursing perspective for a while, and also because I have a poor social life these days.

The average surgeon has 14-16 years of formal education/training after high school. Sometimes I find myself kicking myself when I look back and realize how much time and energy I have spent...

I am not asserting that FNPs are over-ordering diagnostics. Instead, I am saying that they seem to under-workup cases with the appropriate diagnostics, and instead refer to a subspecialist early, compared to their primary care physician counterparts. This is not necessarily a bad thing, as it probably will not affect patient outcomes, because the appropriate work-up will be done either way, whether by the primary care provider or a specialist. But the quickness to refer to specialists may offset the cheaper cost of healthcare that NPs provide. However, I admit this is just based on my observations which may very well be subject to sampling bias.

You should go the extra mile not because the doctor appreciates you, but you should go the extra mile because its better for the patient. I am a physician. I work close to 100 hours a week. When I am not in the hospital, all the nurses have my personal cell phone number so that they can call me at any and all hours of the night about my patients. I come in and see my patients every day of the week if I am in town, even if there is a doctor covering me. I think about my patients while I am driving, while I am eating, and I even dream about my patients, because I am so worried knowing my decisions could mean their well-being or their death. That is going the extra mile on the physician's end. I go this extra mile not because my partners appreciate me, the nurses appreciate me, or the hospital CEO appreciates me. I do it all for my patients. You are not working for me; you do not need my appreciation. You are working for the patient, as am I.

Any member of any profession will start kicking and screaming when someone can do their job equally well for less cost. Imagine the factory workers whose jobs were supplanted by more efficient and cost effective machines. This is just the part of the evolution of mankind. If the studies show that NPs can provide healthcare with outcomes equivalent to primary care MDs but at a much lower cost, then the evolution from MD to NP will be inevitable, no matter how much education the MD's have. As a specialist MD, I have observed one significant difference in the practice style between NPs vs. primary care MDs. It seems the NPs are much quicker to refer a patient to a specialist before acquiring enough diagnostic workup to justify the referral, compared to their MD counterparts. For example, if a patient has back pain, the NP would possibly order some x-rays of the spine, and then refer to a spine surgeon regardless of the results of the x-ray; whereas, the primary care MD would work it up further with additional MRIs, etc, before considering referring. This difference may reflect the difference in education between the NP and the primary care MD, as the MD has many more years of education/residency, and thus feel more confident to work-up these situations before referral to a subspecialist. Again, I cannot prove this practice style to be true with any hard data as of yet, but it is what I have definitely observed amongst multiple referring NPs in the community. If this proves to be true, then the lower cost of an NP may be offset by the increased cost of the referrals to subspecialists that they are ordering. Other than that, I am all for NPs taking the role of primary medical decision makers for patients if they are willing to take the responsibility, even if it means the dwindling of my fellow MDs, for the sake of more economic health delivery.