by Derek Mazique
Between “death panels,” a NICE-style cost effective analysis board, and Obama’s slowly graying hair, one conspicuously absent part of reform are reimbursement rates. Medicare and private insurance typically reimburse for expensive procedures, which ultimately rewards procedure-heavy specialists while discourage those cognitive-heavy services like primary care docs.
The result? As a recent Baltimore Sun op-ed and this very blog pointed out, a combination of pay and burn-out are encouraging med students to pick specialties over primary care. While loan repayment and the US Public Health Service may stop the bleeding, Congress’ conciliatory moves away from true reform may be the death knell of primary care.
What’s primary care to do? Bring in the nurses. Namely, increase the recruitment of nurse practitioners who already perform many primary care duties. This includes increased reimbursement for hiring nursing educators and more funding for building nurse practitioner programs.
Unlike primary care, nursing schools turn away qualified applicants due the lack of teachers and facilities, something that increased cash from the federal government could help to fix. Such a ready and willing workforce could help fill the gap that many Americans find themselves in when looking for a primary health care provider.
The improvements that more NP’s would bring encompass more than just numbers. A recent report in Health Affairs by Kutney-Lee, et al. highlighted that patients’ reported higher satisfaction and would recommend a hospital to a friend if the nursing environment improved.
Nursing’s “patient-centered” model also allows for a personal primary care experience, and nurse practitioners have been proven to lower time on ventilators, complications, and length of stay. And on average, nurse practitioners earn $81,000 a year, almost half of the $160,000 that typical primary care docs (not including the cost of training).
Existing primary care docs could then phase into a supervisory role with a group of NP’s, and see the most complicated patients in a primary care setting before referring them to costly specialists. In this way, primary care docs would still retain their gatekeeper role.
Clearly this situation is not ideal – many primary care doctors want to and love to practice their craft, and shouldn’t be placed out by a reimbursement rule. If Congress doesn’t have the wherewithal to change retrograde reimbursement rates, though, at least federally mandated NP education would ensure that America’s patients don’t suffer.
Derek Mazique is a Clinical Research Coordinator at Johns Hopkins University.
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Related posts:
- What role should nurse practitioners play in primary care?
- Why nurse practitioners and physician assistants will not solve the primary care shortage
- Does the AMA secretly want to kill primary care?
- Should specialists be re-trained as primary care physicians?
- Reader letters: The primary care crisis – don’t take my word for it
- Will nurses be the new primary care providers?
- Primary care-specialty income gap: It’s worse than we think
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A reminder that comments must have a civil and respectful tone, related to the topic at hand. I reserve the right to delete any comment, for any reason, at any time.
Thanks,
Kevin
I would like to also add that Nurses have a better opportunity than Physicians to be “patient-oriented because Physicians in the US are on average, much more scant than nurses. As a matter of fact, the Doctor-to-Patient ratio in the US is ~390:1, and in contrast the Nurse-to-Patient ratio in the California (I could not find anything for a national statistic) is 1:5.
As you can see, nurses can thus have a more patient-oriented approach because, while they are still in short supply, physicians are far more scant than nurses!
NPs and PAs? Do the work of a doctor and get paid like a nurse? No thanks. (Although working as an NP is quite a bit easier on the back…)
I just don’t see why we assume nurse practitioners will stay in primary care rather than going into specialties themselves. The money and working environment is better for them in a specialty office, just as it is for a physician.
I once was a primary care physician…making about $81,000 a year. So I did the work of a doctor for the pay of an NP? Thank god I got out and will never look back.
Why do we have so few primary care physicians? Is it really because the money isn’t there? Or is it a “manufactured” shortage?
There are thousands of people who have the intelligence and skills to become doctors in the US. However, due to the limited number of medical schools there are a limited number of openings for students. And the cost of medical school is prohibitive for many who are otherwise qualified to enter med school. And those who are already doctors like it this way. The situation makes them unique, special, and well-paid. Unfortunately for the rest of us this means increased cost of our health care. It also means that the Peter Principle is widespread. So, rather than being rewarded for practicing good medicine, a good doctor becomes a mediocre administrator and thus deprives the patient of his skill.
I have nothing against Nurse Practitioners or Physician Assistants. However, it won’t take long for them to realize, and understandably resent, that they’re doing a $160K job for only $81K… How long do you think they’ll continue to do it?
What will happen to the nursing shortage if RNs become NPs…?
Something that has worked for group practice (3 PA / 2 MD) in my area has been a staff of 3 PA’s seeing patients in the office for routine exams / etc, with the MD’s rotating office / hospital duties. (there just happen to be more PA’s than NP’s in the area) While the Extenders can fall back on the attending if there happens to be a particularly difficult case, they can build sufficient patient volume that allows the two docs the lifestyle to have more time off & to also see patients on an inpatient basis. Everyone’s happy.
The medical school entrance is controlled by the state the medical school is in. The state allots a total number of funds and seats to each school. If a school disobeys, they lose the funding.
As a patient, I have no qualms about routine matters (history, PE, refills, follow ups, suture removal, counseling about this and that) being done by a NP/PA or whatever.
The main concern I have is that a trained physician has much more hands on experience to draw on in making a diagnosis and treatment. . There are many things that 4-5 year apprenticeships/ residencies teach that aren’t in books.
I prefer the NP I see over my primary physician. Maybe because my NP doesn’t make me wait over an hour in the room and she’s a heck of a lot nicer to me.
It would be nice if there were more scholarships or student loan repayments for those who want to go into family medicine/general medicine.
I don’t think as many people want to practice medicine as we think though. Who really wants to be in school that long?
I have to laugh at all the so-called “health policy experts” who trout out the same old idiot logic that NPs or PAs will be good primary care providers and replace physicians.
Clearly these ivory tower guys dont work in healthcare or have any sense of whats actually going on in the healthcare workforce.
NPs and PAs are running as far away from primary care as they can. You are a fool if you think they are going to stick around in sufficient numbers to become primary care guys. Why would an NP or PA choose primary care when they make DOUBLE AND TRIPLE the money working in a subspecialty clinic? Furthermore, they need ZERO extra training to do so, unlike physicians in which subspecialists are required to train longer than primary care guys.
NPs and PAs respond to the same financial incentives that MDs do. They arent fools–they arent going to work in primary care and choose to take a 50% pay cut right off the top.
Interestingly, I grew up (as most of the world does) in an environment where primary care physicians actually have less training than our Nurse Practitioners. A medical degree in Mexico (as in most of the world) is a baccalaureate degree (plus 1 year apprenticeship), while Nurse Practitioners up here appear to have at least a Master’s – and I’m hearing people up here think that is insufficient training for basic primary care.
Why do we think we need someone with a four-year undergraduate degree, four year post-graduate degree, plus internship and maybe residency to figure out that the boo-boo on your toe is infected?
I think the model at my dentist’s is appropriate – I go in every six months and see someone who scrapes my teeth off, takes X-rays and fields basic issues with mouth care. The actual dentist spends maybe three minutes checking her work and chatting about whatever issues came up. A similar model in primary care should be reasonable. In some clinics we approach it with physician assistants taking a small part of the load, but that’s pretty rare (it seems).
All US health care providers will need to contribute to provide care for those currently without access or funding. However, your piece did not mention physician assistants (PAs).
PAs are also reimbursed by Medicare at the 85% rate, a cost savings. All PAs are trained as generalists in the medical model. In contrast, many nurse practitioners are trained in specialty programs (women’s health, pediatrics, etc). PA education is very uniform with set standards governed by the Accreditation Review Commission for Physician Assistant (ARC-PA) that must be met by every PA educational program; PAs pass one nationally standardized exam developed by the National Commission on the Certification of Physician Assistants (the NCCPA) in collaboration with the National Board of Medical Examiners. There is no one uniform accrediting agency for nurse practitioner education and there are currently several competing credentialing routes.
PAs ALWAYS work in physician directed teams; many (though not most) NPs work without physician supervision. Although their day-to-day autonomy in clinical practice is substantially equivalent to that of the NP, PAs do not seek to practice independent of physician supervision, feeling that interdependent “team” practice is the best way to provide uniformity and equality of care to all patients.
It is important to note that although there are numerically fewer PAs than NPs, most workforce research reveals that a larger percentage of PAs are practicing full time in patient care than formally trained nurse practitioners, and the number of patients seen and prescriptions written by both groups are almost identical, with a slight edge going to physician assistants in most estimates. For example, in the journal Health Services Research, August 2003, the WWAMI (Wyoming, Washington, Alaska, Montana, and Idaho) Center for Health Workforce Studies and Rural Health Research Center concluded that “Generalist physicians make up 76.6 percent of the generalist providers in Washington State and provide 78.9 percent of the generalist FTEs; NPs provide 9.4 percent and PAs provide the remaining 11.7 percent” even though there are numerically more NPs than PAs in Washington, as there are throughout the country. Further, “An estimated 699 NPs provided 330 family physician FTEs (full time equivalents) and 581 PAs provided 411 family physician FTEs.” This reflects the slightly enhanced productivity of PAs when compared to NPs, which may be key in any anticipated workforce crisis.
Other research bears out this trend. The authors go on to state that the productivity of generalist physician assistants is about 75% of that of generalist physicians, which is slightly higher than the nurse practitioner productivity in most studies. This is likely due to the propensity of NPs to work slightly fewer hours per week and to see slightly less number of patients per hour than either physicians or PAs. Therefore, all other things being equal, PAs will have at least as much impact on health workforce needs in the context of health reform as nurse practitioners will.
Both NPs and PAs have “a place at the table” for health care reform.
NPs and PAs seem very good at ordering lots of tests and referrals. They seem to give out more antibiotics as well. I have seen many patients harmed significantly by mid-level providers in situations that were not that complicated. (Misdiagnosis and mistreatment.)
Also now most mid-level providers are asking for basically what I earn in primary care, but without all the hassles such as call, hospital, etc. I do not think they will save the system money. Most are gravitating to specialties where they can earn more than I can.
I don’t think most PA/NP’s would fit in sub-specialties, if they were left to work independently. Even a senior resident/ IM/FP staff (MD, doctors) can’t do the sub specialty work on there own, they basically don’t have enough experience.
I don’t see why PA/NP pay would be higher. All they could help in sub-specialty work is get H&P, put in basic orders, but the care would still be directed by the attending. This is what they do in primary care. Then why should they be paid more.
PAs working in specialties for a long time perform at the level of a junior specialist because they have been working in a narrow area for a number of years. In surgery especially, they do (highly paid) procedures, first assist for the 15% fee, and get incentive bonuses based on reimbursements for these. A local neurosurgery group bills out 100K a month for the PA’s first assist fee (they get back 40K) and the PA can get incentives for 10% of that in their pay. It is not unusual for a specialty surgical PA to make 125-150K annually in neuro, CVT or ortho. In CVT, they take out the bypass grafts to be and first assist at the chest, do ALL of the ward work, procedures on the floor (chest tubes, lines, etc.). This is standard.
So, it is not a slam dunk that PAs will go to primary care, but about 40-45% do, and if financial incentives are there more will.
Nurses can help family physicians and the primary care in general by being “Family Team Care assistants”. Please see http://www.familyteamcare.org
I’m a family doc who has worked with NPs for a long time (not PAs). The editorial makes sense in theory, but in practice we never have a supervisory role–we have a full-time clinical role plus a supervisory role on top of it. Two jobs for the salary of one. Will med students sign up for this deal?
Funny/sad story: I knew a psychiatrist who wanted to be a “real doc” and so went back into family medicine to retrain. Her colleagues told her she ought to have her head examined. She quit family med after internship.
There is a shortage of GI docs in my area. Can we hire more NPs to fill the shortage as well? Perhaps have 5 NPs seeing GI clinic patients with one MD sitting back surfing the internet while the NPs present to them.
This whole discussion assumes NPs can do primary care. This whole discussion assumes primary care, as practiced by an NP is similar to primary care as practiced by an MD.
I would say that a lot of primary care as practiced by an NP can be done by an RN with a few years of experience.
Why not hire a bunch of RNs for 40K a year and save even more money?
That way you could have 10 RNs instead of 5 NPs seeing clinic patients while the MD sits in the office surfing the internet waiting for RNs to present their patient.
Sound’s like a perfect plan to me.
Happy, do not underestimate RNs. *Plenty* of experienced RNs I know could do at least as good a job as the well-meaning but mostly clueless interns that come through our unit — and I’m talking critical care. Also, several RNs I work with make six figures (by working a lot of overtime) and I live in a state where RN pay rates are relatively low. The differences between MDs and RNs are all about education, training and professional duties/role (not to mention respect and paycheck) NOT intelligence or ability.
Catharine I said RN’s could do a lot of what NPs do. We aren’t in disagreement there
your comment about RNs knowing more than interns is just plain silly. Interns don’t know Alot about anything because they are interns and their exposure to any one field of expertise is at most two months when coming out of med achool
All this leads me to only one question. Is 4 years of medical school +residency really worth it. Can you acquire all the same skills in less time?
Happy, saying RNs can do what NPs can do is like saying fourth year clinicians can do what chief residents can do. It’s just plain not true! Regardless, Nurses shouldn’t be able to diagnose and treat diseases as this is the aspect of Medicine, not Nursing.
Shan… I’m not sure if you realize, but the only difference in training between an RN and an NP is a few ethics courses, a couple months of pharmacology training, and a thesis paper. The worth of an NP is ONLY as good as the training he/she received as a RN! And if you think I am lying, request information from any of the ARNP programs throughout the U.S. (which many are, by the way, actually ONLINE degree programs!). You did say one thing correct though… nurses are trained in nursing or advanced nursing (whatever that means) and physicians and PAs are trained in medicine.
No system is going to work unless it is a team effort led by a physician. The second we banish physicians from primary care, this country’s healthcare system will prove that even if you think you have hit the bottom of the barrel, you can lift up the barrel and find something even worse…
Erin: This is simply not true. NP’s take advanced pathophysiology, pharmacology, statistics, advanced assessment, and many, many other courses — and do plenty clinical hours in various settings. Usually a specialty is studied in graduate school, not learned after graduating with a general FNP. However, this is not to say that NPs shouldn’t work under the guidance of a physician, of course they should.
Sorry to tell you, but putting the word “advanced” in front a few one semester courses does not make the course suddenly equivalent to physician training (which by the way is training given by other physicians rather than other NPs). This isn’t meant to downplay the worth of NPs, only to display the truth that this is a mostly nonuniform unregulated profession that is known better for its ability to educate patients well rather than make clinical split second judgments. Which further drives home my point that it is best used in the team model of indirect supervision with a physician always at the helm.
And FYI, I happen to be an ICU nurse of 13 years nursing experience and have watched my profession getting ravaged by the NP independence model. Folks wonder why we have a nursing shortage… well maybe it is because people are only going to school to be nurses so they can be NPs and have the word “doctor” placed inappropriately before their name. What I have seen in my years of practice is good nurses tend to stay nurses because we know our worth. No doctor, hospital or patient could survive without US. However, I watch as nurses who can’t hack it seem to just bow out and go to NP school. That tells me most NPs have far less ability clinically than I do! I know many NPs and I know this for a fact. Its like the old adage, those who can’t do, teach. Like my colleagues and I often say, those who can’t cut it as nurses, simply become NPs. Hopefully one day our ANA will wisen up and stop spending all our lobbying dollars trying to encourage nurses to go play doctor, and rather use that money to elevate the status of the true, good RN who is really out there helping save lives!
Shan, I would take an experienced RN in their field of expertise over an NP trying to practice “primary care” every time. I know of no doctor who can jump from pediatrics to orthopaedics to dermatology to gastroenterology within a a couple years time and claim expertise in all fields seeing patients like they’ve been doing it for years.
I would take 100 RN’s each experienced in their field over an NP trying to practice “primary care”. Because, as an internist I know very well what “primary care” is and what NPs can and can’t offer.
Consider the United States to be the field of primary care. Consider the state of Missouri to be the domain of NP practiced primary care.
It’s but a very small subset of the education and experience required to offer the full scope of practice. Many patients don’t need a full scope. They need someone to refill their synthroid or to schedule their colonoscopy.
That’s why using the words “primary care” to lump in NPs and MDs doesn’t make sense. What NPs offer is vastly inferior in scope of what internists can offer.
Prescribing synthroid and scheduling a colonoscopy is not primary care. Primary care is finding the correct diagnosis for a complaint of “weakness” in a patient with 30 medical problems and 50 medications.
What you need is a medical degree, not a nursing degree to practice full scope primary care.
Erin – I feel sorry for how disgruntled you sound about the nursing profession. I am also surprised at your lack of understanding about the global NP role. It sounds as though your hospital’s NPs might not be trained well but do not transfer your bad experience to all NPs. I live in the Midwest and attend graduate nursing education right now. I take “advanced” classes in pharm, assessment, patho, etc along with the “ethics”. (Imagine what would happen if all health care practitioners had to take medical ethics classes, how horrible.) Besides all the classes I have to take I will do over 600 hours of clinical time with NPs and physicians. And although I do teach I am not incompetent. Statements like yours are keeping the role of the bedside nurse down. There are high level and low level practitioners in every area – bedside nurses, NPs, PAs, and MDs. Your generalizations could stand some “advanced” medical ethics and professional role development classes. Bedside nursing is a great profession. Being a nurse practitioner is a great profession. Being a PA or MD is a great profession. Do what you love and don’t put down others who are doing the same. We should be boosting all areas of the nursing profession not dividing it. You do make some points of interest, particularly that many NP schools allow a fast track for RNs with little or no experience before entrance into the graduate program. I work with one who had an undergraduate degree in science then did the accelerated program and became an RN and acute care NP in just a few short years. Her education was not lacking. Her work experience was lacking and it is unfortunate for the patients she sees. But a physicians group hired her. Interestingly she still works as a bedside nurse at one hospital and as an NP elsewhere. I think NP schools assume that more experienced nurses are entering their ranks and they need to readjust their education style if they are going to fastrack some students.
I am becoming an NP after a 15 year career as a bedside nurse in community and level 1 trauma ED, pediatric cardiac intensive care, and flight nursing. I was a paramedic for years prior to nursing. I am very capable as a bedside nurse. I just want the hours and flexibility that many NPs have. So please don’t be so critical of those of us who don’t want to do bedside nursing for 30 years and have crappy retirement, and I wont put down those nurses who do. You say you have remained a bedside nurse because you know your worth. I wonder if you think you are getting paid what you are worth or if you are getting the respect you are worth. If not, then maybe the NP role would be another avenue for attaining that peer respect. And I think you may learn a bit in the class on professionalism.
Kudos to you “Proud Nurse”. What a disappointment by Erin to her own profession. Clearly she has no concept of the ANA’s mission statement. And I would only guess that she continues to not support her profession by choosing a physician as her primary care provider and not a Nurse Practitioner.
Dear Happy Hospitalist-sounds like you have never worked with an experienced Nurse Practitioner in Hospital Medicine or otherwise. And, because of your views of advanced practice nursing it appears NP’s aren’t employed by your hospital medicine service. What a shame. Let me know if you’re ever in the midwest and we’ll demonstrate how well NP’s work with Hospital Medicine Programs. And, if you’re ever in Iowa, I’d be happy to show you my successful INDEPENDENT Family Nurse Practitioner clinic of 4 years that provides superb primary care to it’s rural residents. Thank goodness my bank of 2500 patients and the great state of IOWA understands what a Nurse Practitioner is and trusts me enough to fill their Synthroid prescription without a physician. Makes you wonder why the physician’s office 10 miles away closed. Hmmm…….
The day an NP practices quality inpatient cost effective and full scope hospitalist medicine independently without any supporting internist or family medicine MD staff is the day hospitalist medicine as medical profession dies. And the day I exit the field. I don’t have to worry though because I know that an NP and DNP is woefully underqualified to provide anything close to full scope hospitalist medicine (or my definition of primary care) independently without being nothing more than a triage service.
In fact, that is the day all of medicine dies. At that point, I would recommend all medical schools shut down for good and all future doctors, surgeons included, attend nursing school NP school and DNP school to receive their respective degrees
As for my synthroid, you can fill my synthroid script anytime you want, I’ll let you know what the dose is. If that is in fact what you consider primary care, I have full confidence you have a thriving independent primary care office. Unfortunately, none of my hospitalized patients would meet your standards.
Oh I forgot, I trained NPs for a while as they came through rotations on Happy’s service. What I found was a frightening lack of basic science skills. Would I want an NP carrying for me independently. Absolutely not.
Proud Nurse and DNP-
Your comments precisely the haughty attitude that has disgusted me about the DNP process being forced down all of our throats. So now I am uneducated and unprofessional for feeling that the NPs are not equivalent to physicians and, as a whole, leaving us with a deepening gap in this nursing shortage crisis? Seems to me the lack of education lies in your court. And your attitude only antagonizes physicians (as in these above posts) to the point where their disdain gets taken out on the whole lot of the nursing field. When are you all going to learn. We aren’t doctors. If you really are “proud” nurses, you would stop trying to turn our profession into something that it isn’t.
You can be disappointed all you want about my viewpoint, but I am not alone. Many other RNs feel the way I do about this. You situation of choosing to go into an NP field after 15 years of hard work so you can take it easy for more pay is fine. You obviously have been through it all and will probably serve to be a great NP. But that is just my point. Most NPs don’t do this. They go straight through in a fast track fashion for the greater glory and higher pay.
And yes, I do get frustrated at times in my job, and yes, I do wonder how close I am to burning out. But if I ever decide I want to be a supporting midlevel practitioner, I will go to NP school. And if I ever decide I want to be a independent practicing “doctor”, I will go to medical school.
Erin – I agree with you. Nurses should not act like physicians. I left good grades in pre-med because I did not want to be a physician. I wanted to be a nurse. And all the NPs I know, except one, understand their role of being a mid-level practitioner (which is a dumb term). I will never have the academic knowledge of any physician and will always seek their knowledge when needed. I think the NPs in your area seem much different than here. I have only heard of one NP ever saying she was a doctor just because she has a doctorate degree. This is very confusing for patients and practitioners alike. Patients need to know who is treating them. I will not feel embarrassed to present myself as a nurse. Being a male nurse causes me to correct patients frequently. And I am proud to be nurse. But the thing I notice about MDs is that they don’t use degrading generalizations about other MDs. They show each other professional respect as a group, not always as individuals. And that is something I feel nursing needs to improve upon. To put unprofessional generalizations out there about all NPs does nothing for any nurse.
MDs, PAs, and NPs must understand the different roles each has and we must respect each others roles and experience. Can NPs function just as well as MDs in primary care – the evidence is there that they can. These studies looked at NPs working under a traditional NP – MD relationship. They always had MDs to consult with or upgrade the patient to. For the majority of patients in primary care, an experienced and well educated NP can perform well and safely, and the patients prefer the NPs. I think your experience of the NPs in the ICU is different. NPs that specialize must be very careful about role confusion and remember that they are nurses first. The same with PAs – they are not NPs and should not function the same. The best surgical practices I have experienced employed MDs, PAs, and NPs in appropriate roles.
I hope to be able to bring a nursing perspective to primary patient care whether that ends up being in a practice or hospital setting (maybe an ED). I have always thought that if MDs had some nursing education they would be much better practitioners in regard to treating the entire patient and not just the diagnosis. Since I have no ability to get MDs some nursing education that they can take back to their practice, NPs have the opportunity to elevate nursing practice into primary and specialty care. This should be seen as a great thing for patients, nurses, and physicians. I know many physicians who specifically take their children to see the NP at the pediatrician’s office for general health issues. That is quite something if you think about it.
I am sorry if I came across too strongly but I do think generalizations about the NP role you made are not objective and could be bringing nursing down instead of building us up. Nurses have been providing primary care for a very long time. And now that we are being recognized as capable providers and getting reimbursed for our care (not practice like MDs) we should recognize this stride. The DNP who comment above is a great example of how the NP can be integrated into primary care, serving an under-served population and doing so independently. Is she or he making the same clinical decisions as every MD, no. But every MD or DO is also different. I am proud and happy that the DNP is providing care to 2500 under-served. Not just primary care – but nursing focused primary care.
I do agree that nursing schools are doing us a disservice by graduating well educated by under-experienced NPs. Physicians reading this should take note that years of bedside nursing practice needs to be an integral part of your decision to hire an NP. Someone who fastracked through their RN and NP education without spending years as a bedside nurse is not a sign of initiative and greater intelligence. It is a sign of under-experience and lack of dedication. I say again, integral to the role of the NP must be years of bedside nursing prior to NP school. It is also not fair to say that a bedside nurse with years of experience is better than an NP with little experience. They are two different jobs. I could not function at the NP level with what I have learned through my years of experience alone. I have learned a lot in graduate school and will learn a lot more. And I certainly could not do the job I do now strictly through what I am learning in graduate school. Two different jobs, two different levels of care that equal in their relevance, importance, and skill level but differ in their dimensions. This combined with all my clinical time and my 15 years of experience is what will make me a competent care giver – not any of those things separately. Despite my experience and education I will come out of NP school as a novice NP, a very experienced RN but a novice NP. I will need both NP and MD mentors to better learn the profession and care. But this is the same with every profession. I hope the RNs I work with when I am a novice again realize that I am in a new role may need a little extra assistance at times. I currently work in a large teaching hospital. Even the residents that train at this hospital and then get a job here, come out at the novice MD level. And they practice at that level. It should be expected. And we, as nurses, give them a break for a while as they are getting up to speed in their role transition from experienced resident to novice attending MD.
It seems to me that most of these posts demonstrate role confusion about different practitioner levels and the transition from novice to expert. I would recommend that anyone who works with new MDs, RNs, NPs or PAs types in novice to expert in Google and briefly read about Benner’s stages of clinical competence. You all might better appreciate the challenges facing yourselves and others you work with as they transition their job duties.
My friend, who is a nurse, used to see an NP but has just changed to an MD. The reason: the NP failed to accurately order a routine test that would have caught my friend’s cervical cancer earlier and saved her months of unpleasant treatment. Sure, my friend’s NP was really nice but from a skills standpoint, my friend is much more comfortable being treated by the MD.
“PAs working in specialties for a long time perform at the level of a junior specialist because they have been working in a narrow area for a number of years. In surgery especially, they do (highly paid) procedures, first assist for the 15% fee, and get incentive bonuses based on reimbursements for these.”
This is erroneous. Do PAs do surgery? No, they first assist. Claiming that a PA is equivalent to a “junior surgeon” is an absolute joke. Sure, they can manage post-op patients and see people in clinic, but they DONT do surgery and therefore its ridiculous to suggest they are equivalent to a “junior” level specialist who spends a lot of their time doing something that PAs NEVER do–practice surgery.
When PAs are successfully running their own OR cases with no supervision, THEN you can claim that they are equal to “junior” specialists. What a joke.
Four recent cases (in the last year) with 3 different experienced NPs:
1.My NP ( a wonderful lady who usually knows her limits) sent home a pt with “bronchitis.” I saw the pt as she was stumbling out the door. She was obviously septic. Disposition: ICU.
2. Same NP almost sent out a hypotensive pt with Lemierre’s Syndrome before I stopped her. Disposition: transfer to Tertiary Care Hospital, ICU for 10 days. My NP has learned her lesson (I hope). She runs potential sickies that mistakenly get triaged to her by me. I also review her charts.
3. I took my daughter to see an NP for an elbow injury (insurance wouldn’t pay if I order the XRay myself, and her doc was booked). XRay had an obvious sail sign and NP had no clue. She said the Xray “looked OK. ” I asked to see the film, placed the posterior splint on my daughter (NP did not know how), and called the orthopedist who looked at the Xray and saw my daughter the next day for her elbow fracture. She was casted for 2 weeks. This NP simply had no idea how to evaluate pediatric elbow injuries–yet she sees them.
4. Different NP saw my son for a volar plate injury to his middle phalanx (again, I had to go because of insurance). She had never heard of volar plate injuries. I read the xray, fitted the splint, did the followup.
My experience is that NPs are great if they know their limits and are not placed in a position where they have to see severely ill pts or pts who present with unusual problems. The idea of them practicing without backup scares the heck out of me.
I have no experience with PAs.
Physician assistants will likely help too. In California they have just passed new legislation saying that a doctor can supervise 4 PAs and only sign off on 5% of charts, meaning a lot more patients can be seen.
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