Comments on: Will nurses solve the primary care crisis?

By: Lila

Lila — Sun, 13 Sep 2009 16:15:53 +0000

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.

By: jsmith

jsmith — Thu, 27 Aug 2009 01:33:20 +0000

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.

By: joe blow

joe blow — Thu, 27 Aug 2009 00:24:16 +0000

“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.

By: My Experience

My Experience — Wed, 26 Aug 2009 06:38:41 +0000

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.

By: Proud Nurse

Proud Nurse — Tue, 25 Aug 2009 21:59:47 +0000

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.

By: Erin

Erin — Tue, 25 Aug 2009 19:13:28 +0000

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.

By: Happy Hospitalist

Happy Hospitalist — Tue, 25 Aug 2009 18:24:05 +0000

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.

By: Happy Hospitalist

Happy Hospitalist — Tue, 25 Aug 2009 18:22:51 +0000

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.

By: Respected DNP

Respected DNP — Tue, 25 Aug 2009 17:41:42 +0000

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…….

By: Proud Nurse

Proud Nurse — Tue, 25 Aug 2009 16:12:02 +0000

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.