The AAFP picks a fight with nurse practitioners

The AAFP picks a fight with nurse practitioners

The American Academy of Family Physicians (AAFP) recently issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.

More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”

AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.

It is unclear how this plays out in the real world but, intuitively, we all want physicians in a pinch. Researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They wrote “appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.” But they also acknowledged that the research was limited.

There is no question that nurse practitioners can provide excellent routine care. For identifying and managing complexity, though, physicians’ far deeper training is a big advantage. In other words, difficult, expensive cases are likely to fare better from a physician’s care.

AAFP can hardly be blamed for wanting to dispel the notion that physicians are exchangeable with nurse practitioners. But does anyone seriously think that nurse practitioners will displace primary care physicians? Well, in some venues, yes. In the onsite and retail clinic sectors, some firms – not mine, but others – see nurse practitioners as cheaper labor and just as good as doctors. This approach, championed most aggressively by the big box drug retailers like Walgreens and CVS, bets that, in the market, lower short term cost will beat higher long term value. While AAFP may argue, correctly, that nurses don’t equal doctors, the prospect of a protracted battle with powerful Fortune firms is daunting.

At the same time, AAFP’s focus on nurses appears to ignore the more important fact that specialists now provide a significant percentage of primary care services. An August 2012 Archives of Internal Medicine study found that 41% of primary care office visits were provided by specialists. (This study defined internists and obstetricians/gynecologists as specialists, so the numbers may be inflated.)

A more robust study three years earlier examined more than a billion patient encounters between 2002-2004 and found higher numbers. Nearly half (46.3%) of specialist visits were for preventive care or routine follow-up of patients who the specialist had previously seen. New referrals accounted for only 30.4% of all visits. Many of these visits could be handled competently and far more cost-effectively by a generalist.

To some degree, patients’ use of specialists for primary care reflects the primary care physician shortage. But a different problem is more pernicious: patients – particularly if they’ve had a previous condition, like a heart ailment – often believe that specialists are more qualified.

Which brings us to a difficult question. Why has AAFP taken a public stance against nurse practitioners extending primary care services, but ignored specialists usurping a significant portion of primary care business?

One answer is that primary care has become demoralized and insecure, the result of decades of being treated as a lower caste in medicine, and that nurses are less formidable opponents than specialists or corporations.

Primary care is in decline because it has been compromised by a health care industry that wants direct patient access to lucrative downstream services. But primary care’s leadership also has complicity, because it has failed to compellingly convey primary care’s value and allowed others to define it. It has been meek in defining models that can drive efficiencies, or in highlighting the mechanisms of scale essential to market power. Nor has it partnered with more influential groups, like business leaders, whose interests – lower costs and better outcomes – are aligned with its own.

Fighting with nurse practitioners will buy primary care physicians little. Worse, it distracts precious resources from approaches that can keep health care businesses from distorting primary care’s appropriate role and specialists from encroaching on primary care’s work. Focused on the wrong problems, primary care will continue to flail.

Nothing will change in primary care or the larger health care system until there is a new results-based activism in policy and the market. Primary care must receive reimbursement that is commensurate with its measurable full-continuum value, allowing it to invest in clinical decision support tools and management capabilities, and presenting it as a meaningful, data-driven answer to the monstrous health care cost crisis.

Brian Klepper is Chief Development Officer of WeCare TLC and blogs at Care and Cost.

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  • Kristy Sokoloski

    Good article but now I have a couple of questions. It has to do with the following statement, “Primary care is in decline because it has been compromised by a health care industry that wants direct patient access to lucrative downstream services.” Has there been any research done asking for ideas from all parties involved (including the patients) on how to change this? My next question has to do with this statement, “One answer is that primary care has become demoralized and insecure, the result of decades of being treated as a lower caste in medicine, and that nurses are less formidable opponents than specialists or corporations.” What was the cause for the start of this in decades past?

    • LeoHolmMD

      On your first question: Large health systems do not want to expose to patients that they do not give a crap about Primary Care. It is not done for it’s own sake, but to harvest the “big ticket” items like scans and procedures. On your second question: almost the same answer. If you have a provider that uses clinical skills instead of scans, provides specialist care without referral, trys to keep people well instead of sick, reduces health care costs and utilization and does it for a fair price…that person needs to be eliminated in our current health system. Patients highly value Primary Care…but who cares what they want?

      • Kristy Sokoloski

        Thank you for the explanation.

  • lauramitchellrn

    The corporate types don’t understand that Nurse Practitioners (NP) are not interchangeable with physicians, only that they cost less, which is demeaning to both physicians and NPs. In an ideal world, physicians and NPs would practice COLLABORATIVELY (a novel concept in today’s world of every shrinking reimbursements), each discipline being effective within their respective scopes of practice. I think in some situations, NPs can provide appropriate primary care, especially in areas where physicians are scarce (inner-city, rural and frontier counties) and with today’s technologies, physician back up is a Skype call away Unfortunately, I think AAFP’s reaction is somewhat “knee jerk,” and comes across as being about money and not about the patients.

  • Randall Oates, MD

    What if there was a Collaborative Primary Care Guild focused on bringing value to patients based on evidence?

    • ProudOkie

      Hi Dr Oates,

      We cannot collaborate. Physicians see us as second class caregivers and we see ourselves much differently. I own a private NP practice and already collaborate with specialists routinely. The battle will never end. I hope my NP colleagues never subjugate themselves to a PCMH unless they are a full partner in every way. Family practice physicians have burned the bridge and they forgot to cross it before they set it on fire.

      • southerndoc1

        ” Family practice physicians have burned the bridge and they forgot to cross it before they set it on fire.”
        Great line. That describes exactly what the AAFP has done in creating the PCMH.

        • ProudOkie


          Thanks for the comment. I want you to know that although I am highly opinionated and we are at opposite ends of the spectrum concerning all of this, I highly HIGHLY respect family practice physicians on the front line. They will not include my private clinic in any of their plans in my area. I am okay with that. My “beef” is with the constant degradation of my profession.

          Here are a few things the AAFP (and many physicians on this blog and others) continue to do despite the fact it is highly offensive to NPs. They do it with the full knowledge it offends us.
          1) Knowingly utilizing the term “mid-level” or “physician extender” with the full knowledge it highly offensive to us. They just don’t care. Every time the term is used, the wedge is driven a little deeper. We prefer to be called “Nurse Practitioners”.
          2) Continuing to relate us to the degradation of healthcare services in America. My care is impeccable and were it not for access to me, many patients would wait weeks for an appointment. For whatever reason, many patients in my area transfer to our clinic from local physician clinics. Their primary reason? Lack of respect for them and their healthcare decisions. I am not blowing a horn, just stating the reality of healthcare.
          3) Concerning “disguising” myself as a physician. No one seems interested in listening to the fact that we take every precaution imaginable to insure this does not happen. Nothing I do will make family practice physicians happy. I have done the following in my clinic: placed NURSE PRACTITIONER CLINIC on our sign, REQUIRED patients to sign a statement informing them there are no physicians in our clinic and informing them they will only receive care from an NP unless they are referred to a specialist, clearly placing my state license right in their face as they are weighed to further inform them I am an NP. Introducing myself to everyone as a Nurse Practitioner.
          4) Referring to us in the third person as though we are tools or property. This is another attempt to degrade us with full knowledge of what the individual or company is doing. Examples include articles about utilizing NPs to increase income.They just don’t care.

          Southern, the truth is – no matter what I do, how hard I try to distinguish myself as an NP, how hard I try to go overboard to comply with State BON requirements, physicians will not be happy with me. Until I say, “I am less educated than you and cannot compare the time I have invested to the time you have invested and I am not qualified or worthy to own a private practice”, physicians will not be happy (please don’t cut and paste this quote and say, “you got that right”). I don’t know what to say about that. I am qualified to perform the services I offer – patients are safe, happy, receiving evidence based and knowledge based primary care services and would not leave our clinic if offered an alternative. I cannot speak to the differences in time served between our two professions. All I know is I am competent in the provision of primary care dermatology, cardiovascular, immunological, pulmonary…..whatever type of primary care services and our patients/customers lack nothing. I KNOW this. At this point, if I were to shut the clinic down and go to work for a primary care physician in the area, it would be a DISSERVICE to our customers. Access would decrease, the variety of services would decrease, my satisfaction would decrease, and everyone would lose.

          So please don’t blast back at me, I respect you and your opinions. I fire off so aggressively because of the disdain physicians have for me and my profession. What have I to lose? No matter what I present or believe, my profession will be belittled. And when someone runs out of arguments, they will proceed with vicious ranting attacks (ala kjindal) and just fan the fire and make it burn ten times hotter.

          • LeoHolmMD

            You made several good points. The AAFP is not doing anyone any favors. There is no way that one profession can try to control another in the way they are suggesting. If there are real differences between FMs, IMs and NPs, those need to be clarified in real terms that patients can understand. Otherwise the real issue is going to become the disparity in pay grade between one or another for providing the same service. The flipside of the same issue: how to account for the disparity in educational investment for doing the same job. You are right about the PCMH for sure.

          • SR

            Why not eliminate physicians in primary care if NP/PAs can fulfill this function? I think that they could provide a low cost service that patients could choose; if patients want a physician, they could “bump up” to a specialist level that would require a higher co-pay. Then consumers could be the judge of what worked best for them.

    • Doe Gasque

      Dr. Oates, I would love to keep the focus on improving the health of our patients using evidenced based practices. I would love to help you form such a Guild in order to find solutions to the problems we are all facing in health care.

  • Jonathan Coppin

    Since when are internists automatically
    specialists? More internists specialize than family medicine docs, but many of
    them still do general primary care practice as well. Also, a lot of younger
    women use their OB-GYN as their “primary care” because they have no
    medical conditions to be managed and are just going to get their WWE from them.
    This 41% of primary care office visits being with specialists put out by the
    Archives of Internal Medicine is certainly inflated.

    • Kristy Sokoloski

      I used my OB/GYN for a good number of years as a Primary Care Physician but then over time she hinted that she would rather be the specialist than the Primary Care Physician. Plus, they told me at the time that I needed to have someone that could help take care of things like colds which she was right to tell me to do that.

  • Dave Mittman, PA

    Both PAs and NPs have been providing high quality primary care for many years. Ask the Army, Navy, Air Force, VA, Public Health, Kaiser, and the FIFTY PERCENT of US physicians in private office practice who work with us. Fifty percent, think about that. Only in medicine would someone hire colleagues to run satellite clinics for them and have the groups that represent them say that those same people are in effect providing second class care. Yes, the AAFP said that NPs (and PAs by inference) provided second class care. If so, then why are their members falling over themselves to hire us? Something is not true. Why did the IOM say our care is good. Why does the military rely on us so heavily? The US Army Flight Surgeon of the Year for 2012 is a PA. Are we really fooling everyone, or is this more about turf and economics and less about seeing earaches, sore throats tinea and the like?
    Dave Mittman, PA

  • buzzkillersmith

    Primary care might not be dead, but it was coughin’ up blood last night. I say hand it over the nurses and move on. That might be bad for the country, but what has the country done for us, anyway. Subspecialize, young med student!

    • rswmd

      The lunatics running that AAFP think that having a very public mud wrestle with the NPs for who gets the crumbs from the health care table is a good way to increase med student interest in primary care . . . I think not.

  • Dayna Gallagher

    Nurses are heaven sent, Their effect is massive. They educate future
    nurses, apply the cures, wipe the feverish brows, do what others will not do, console the suffering
    & the dying & their loved ones. We want them to be there for
    us forever.. They are Our Nurses.
    Nurse Education/training does not
    include going to medical school, internship, residency, inclusive of
    passing mandatory medical board examinations.. Absolutely unchanged for the PA.
    In my opinion, this
    thoroughly applies to Advanced Practitioners, providers, & payors thereof. Nurse practitioners alone extending primary care services, is
    beyond their realm of practice unless it is under the direction of a
    Physician’s and all of our nurses & PA’s must on all occasions
    state such and act accordingly with no compromises, including engaging a battle, as we know lives may depend upon

    Thanks very much for this forum.

    • ProudOkie

      Is this an opinion or do you have evidence to support your belief? NPs in 17 states and DC already provide care completely independent of a physician. Have you heard of any drop in quality of care or read of any preventable deaths related to NP care in these states? No, you haven’t. Time has already vindicated us as independent providers..

      • kjindal

        To be truly independent and “equal” to MDs in primary care I think you should:
        a) take and pass the board exam in FP or IM
        b) have NO collaborative agreement with an MD & independent malpractice insurance
        3) denounce the “doctorate” of NP degree as an exercise in pure deception.
        Once you’ve done those things then maybe you guys will be treated almost as equals (even though you didn’t do a rigorous residency with q3 night 36hr shifts etc.)
        Even then, what I see working with NPs (and my colleagues quietly, but universally, agree) is that NPs just aren’t as smart as MDs, not having gone through a highly competitive process starting from a very young age. Maybe much of med school & residency is superfluous, but when I’m medicare-eligible (i.e. old & sick), I want someone smart & with good judgment, not just someone with a long white coat, stethoscope, and lots of unfounded egoism.

        • ProudOkie

          Thanks for sharing what you think.
          a) your field doesn’t set the standard for my field.
          b) I would shed the need for a physician signature for prescriptive authority faster than you would scrap my profession. I already pay as much as a family practice physician for independent liability insurance so you have your wish there. Yes, he is not on my policy..
          3) I will graduate in the next year with my DNP. Feel free to attack further.

          Concerning your quiet colleagues, who cares? They are not the final word on primary healthcare. Their opinion is like an elbow.

          When you are on Medicare, you can select a physician instead of an NP. You will never have to deal with me. Many others will choose me and that’s okay too. Though I understand the ability of a customer to select an NP in the free market is not okay with you. So we agree on a customer’s right to choose at least?

          Please continue with the bickering and opinion based attacks.

          • kjindal

            Your arrogance continues to impress on this blog. And are you saying the DNP is not about deceiving patients? Do you think when you call yourself “Dr.Okie” they are aware that you’re not a Medical Doctor? I’m glad the AAFP is finally trying to create some awareness. And when I’m medicare age, primary care MDs will have gone the way of the dinosaur, mainly due to medicare policy at reimbursing NPs 85% (or maybe by then, 100%) of MD fees.

          • Doe Gasque

            kjindal- When I enter the exam room, I says what we all do- “Hello, I am Doe Gasque, a family nurse practitioner” When they call me “doctor” I correct them sometimes MANY times. I sometimes explain what I do and what the differences are if they don’t know, but most of my patients already know what a nurse practitioner is.

          • kjindal

            “I sometimes explain what I do and what the differences are if they don’t know…”
            so can you please explain to me what is the difference between what you and I do. Specifically please state some things that you do that I do not, or cannot.
            And I am sorry you (and Okie) feel offended, that wasn’t my intention and I am still unable to find anything I said that could be construed as “name calling” or a personal attack. Again,not meant at all. I’m just saying that there’s a bit of hypocrisy here, saying you do what an MD does (but better), yet you’re not practicing medicine. And btw, practicing medicine is diagnosing & treating disease. Wellness is good, but advising patients on healthy lifestyle, wt loss, quitting smoking, good habits etc. can be done by many many others parts of the team e.g. social workers, RNs, LPNs etc. What CANNOT be done by them is knowing when a statin (since you love that example) is indicated, what are it’s side effects, what meds it interacts with, what should be looked out for, and yes what is the NNT in order to prevent one cardiovascular event on such a drug (I am thoroughly impressed, btw, that you are able to discuss such abstract statistical principles with your patients).
            There was another post recently espousing the virtues of the NP, that if you read it closely, has the same tone as many of the posts here, of the “I am an NP, so bring the best of medicine and nursing to the table, unlike a primary care MD who doesn’t know how to be compassionate or take the time to listen, but just prescribes those evil drugs, and further he’s in bed with big pharma…”. Check that post out, very enlightening.

          • Doe Gasque

            It would be the part where you say that nurse practitioners aren’t as smart as physicians. That is unkind and untrue.
            I read the comments that you found offensive as being directed at the health care system in general and not a physicians in particular.
            I agree that nurse practitioners often speak of the physician in one dimensional terms, but the pill pushing, 30 patients a day seeing, never listen to the patient physician is rare in my experience. Even then I usually think that they are completely burned out. Just last week, I had a PA tell me as she was showing me around the new locums site, not to let the patient talk much because before you know it, they will be telling you all of their problems. I have seen nurse practitioners write for dangerous combinations of drugs because the patient will be mad if they don’t give them Vicodin, Soma and Ambien.

            As the author of the article points out fighting with NPs is just a distraction from the real problems in our healthcare system. In all the time you spent arguing with us, I missed your solutions for the primary care shortage.

          • kjindal

            You are backpeddling from your earlier statements about pill-pushing (“ANOTHER pill to the mix…”) MDs who treat patients as diseases instead of “seeing the whole patient”. And you’ve made several unfounded assumptions about physician training. How would you know what med school & residency are like? In Internal Medicine residency I actually had very little trauma exposure, even in a large NYC hospital. That’s primarily for surgeons and ER docs. And we did plenty of outpatient medicine, only it’s foundation was science- and evidence-based.
            Anyway the solutions for the looming primary care shortage, as I and many others have said before on this blog, are very simple – INCENTIVES! If medicare were to stop paying so much for procedures and so little for cognitive E&M codes, it’d take a few years for those incentives to translate into more PMDs but eventually it’d work. But the answer is PHYSICIAN-LED primary care. I think there’s a very useful role for NPs and PAs, but more in terms of coordination of care and continuity, rather than as primary decision-maker. Incidentally I work with some great NPs, and they’re extremely competent but often consult me with management questions, which I appreciate.
            I don’t think you should take this personally, or as an affront to your competence. As you said, for the future or primary care, a joint solution is absolutely a must, but “separate but equal” isn’t the answer.

          • ProudOkie

            I respectfully disagree. We do just fine in our NP owned clinic. We are surrounded by excellent specialists and they take over when we need them. Again, I understand and respect your opinion, but NP owned clinics are operating safely and successfully all over our great country. There is no debating this and there is no debating the fact there are no anomalous patient deaths because of these clinics. Independent NPs in states without onerous restrictions are doing just fine. But, I completely understand your opinion. If you we’re in my area, I could refer my adult patients to you for those who require IM care. You, as a specialized adult internist, would be an asset and a resource to add to my arsenal for those patients who I feel need your specialty. As a specialist and not a family practitoner, The NPs should be utilizing your skill set. Not sure we disagree on too much.

          • Robert

            Your lack of emotional and social intelligence is why you are not a nurse. You inability to see how your actions translated into name calling is, as I said, where you are falling short. That is the difference between what we do and what you do. This is why some patients prefer to see NPs than physicians. Get it? We are trained for what we do, and medical students do not receive RN/NP training. RN training is a requirement for NP training. See? We have a different training model than physicians. We are not attempting to be something that we are not. Nurses have a very, very long history in civilization. The medicine man always was a medicine man. Nurses always have taken care of the sick, the needy, the poor, the dying, etc. NPs are expanding the role a little to be able to provide a certain amount of care to patients. One doesn’t need to go to medical school in order to diagnose a common condition. People do it all the time, which is why we have OTC medicines for crying out loud.

          • Robert


            Even as a staff RN on telemetry, when I enter rooms, patients many a time have called me “Doctor.” I always correct them. Why, after all my training and hell spent in nursing school would I want someone to believe that I am a doctor, i.e., physician? I mean come on. How ignorant for one to believe that an RN would want his or her patient to think that he was a physician, as though a physician is somehow better than an RN. People are really stupid. Nursing has many talented minds.

          • Robert

            Well, Kjindal, the term “Doctor” has always been, even before the USA product “MD”. So, in this regard, I agree with you that only physicians should introduce themselves as “Doctor” …. I believe having a DNP is a good idea for the NP profession, but “Doctor” should be reserved for physicians because they have been calling themselves “Doctor” forever. Physical therapists require a doctorate, but they do not call themselves “Doctor”…, at least not in the medical center in which I work. However, at a prominent rehab facility in Philadelphia, physical therapist do indeed call themselves “Dr. …”, and the physicians I have seen interact with them respect that fact. This has nothing to do with the fact that physicians could, with training, do exactly what PTs do. It is that PT is now a specialized field, requiring a doctorate, and oversees itself. Like this, nursing is going to achieve the same end, even if you cry about it.

          • kjindal

            ” your field doesn’t set the standard for my field…”
            so what exactly is your field? on one hand, some of you say that you “practice” nursing, not medicine. But on the other, you say you can do what MDs do as well as us. If you are diagnosing and treating with labs/imaging/referring to specialist/ prescribing meds, then that is the practice of MEDICINE. And if you want to do that, why shortcut it? Isn’t that disservice to patients?

          • Doe Gasque

            Would you please define the practice of “medicine”. Is a mom giving her baby Tylenol practicing medicine? Is a Nutritionist telling her client to eat healthier practicing medicine? I think part of the problem is the “medicine” is ever expanding its boundaries.
            No, we are not short cutting the process. I can’t speak for the whole nursing profession, I keep my focus on the whole patient and how we can work together in the context of their lives to improve their health. I don’t see a “Diabetic” or a “hypertensive” in front of me, I see a person who has an unhealthy lifestyle, often living in poverty with many issues that have nothing to do with a Statin Deficiency. I am so frustrated every day when I have patients arrive with as many as 20 medications with little improvement in their quality of life.
            I do practice collaboratively, just as I am sure that you do. None of us is in this alone. Finding solutions is challenging. I think we need more focus on primary care and less on the specialists. I think we need to find ways to complement each other and keep the focus on improving the health of the patient.
            What are your solutions for the increasing health problems of our country? How are you managing all this in your practice?

          • Robert

            Your lack of understanding of what RNs and APNs do is where I believe you are falling short herein. And, just to comment, your comments belittling DNP education is great, but, again, unless one has done the training or is directly involved with educating DNP students, I do not believe you are in any place to comment about the education as some sort of authority. The only reason one needed a physician license to prescribe medicine in the past is because physicians stole prescribing rights from pharmacists via political action. I mean, let’s be real here, pharmacists know way more than physicians about medicine. Like this, pathologists know way more about pathology than physicians. But, pathologists do not go around saying medical training is inadequate, thus medical doctors are not as good as we. Do you see the underlying problem with you mind? You are the product of your own suffering.

        • Dave Mittman, PA

          Did you really say “you are not as smart as us?” I bet I am. I bet many of my PA/ NP colleagues are. Let’s meet and do Jeopardy. $100.00 on me. When will you be in NYC or NJ?And besides, do you really need to be as smart as a neurosurgeon (OK, I’ll bite) to provide good primary care?. Answer: NO. We have proved it. You have to know primary care and listen well and care about people and have them come back and see you if they don’t feel better. The operative word is care.Sorry to bust the bubble. But the smartness card is like being in Junior High School again. And when can I sit for the FP exam?God, you guys don’t get it. No wonder the whole thing is in shambles. Dave
          Post as Dave Mittman, PA

          • michaelhalasy

            Not only that, but I know of more than one PA that could crush the average physician in a test on their field…There is one PA in Wisconsin in Infectious Disease that is smarter than ANY ID Doc I have ever met……. But who cares? I have a research doctorate in addition to my PA…so I must be stupid too right? Talk about insulting. Mike

          • southerndoc1

            Neurosurgeons the epitome of intelligence? Not!

        • Nancy Foster

          My child had the “textbook” signs and symptoms of Kawasaki Disease. Board certified pediatrician Dx’d him with a “staph infection of the skin” and Rx’d 10 days of antibiotic. I was unconvinced and asked if he might have Kawasaki Disease. Physician said “no”. I was still unconvinced. Returned to pediatric office and asked to see Nurse Practitioner who immediately recognized Kawasaki Disease and sent us to the nearest children’s hospital for treatment. Lesson learned: the smartest “provider” with excellent judgement and clinical skill that day was the nurse practitioner.

        • Robert

          What NP said he or she is trying to be equal to physicians? Can you please give me the direct quote and source? Your manner of condescending up on others reflects your disrespect for people. I could belittle you by saying I would not want someone smart with a lab coat and medical training to treat my loved ones, if that moron thinks he is better than my loved one, who just so happens to be a nurse practitioner. Do you see the missing emotional intelligence? Just because you calculate nonsense doesn’t make you any more or less intelligent than another. What makes you think that there are not smart nurses with good judgment? Do you know that major universities train nurses? Do you know of nurse training? Have you done it? Are you a licensed RN? Do you even know what RNs do? Obviously not. And, for your information, I where a white lab coat because it is required, not because I am trying to be like a disrespectful fellow who looks down upon his own patients.

      • kjindal

        “do you have evidence …”
        do YOU have evidence that an LPN couldn’t do what you do? On the spectrum of [CNA - LPN - RN - NP - board-cert MD] an NP is closer to RN or LPN than it is to MD, in terms of years & intensity of training (ignoring the much more selective process for MDs).

        • ProudOkie

          No, I don’t have evidence. Do you since you are bringing up a red herring? I DO have evidence comparing me to you. Please refer me to the studies to which you are referring. Thanks!

          • Gail O, RN MSN

            As a master’s prepared nurse educator, I can tell you that LPNs do not have the education, critical thinking skills and the hours of hands-on practice it takes to be an NP of any kind. In our clinics, NPs and PAs are referred to as “physician extenders” because while the physicians see the kind of chronically ill patients who require complex medical decision-making, the extenders are taking care of strep throat, rashes, well-established patients, low-complexity acute injuries and diabetic education. Necessarily imbedded in nursing practice is the intelligence to know your limits and refer to the physician as appropriate; that’s already accepted as true of RNs at the hospital level who call the doctor when it’s critical to patient care.

            Additionally, a high grade-point average and multiple letters of recommendation are required for entrance into NP programs. I think you’d be surprised to know how well many nurses have scored on MCATS and how many have become doctors in our neck of the woods. Please do not denigrate the choice to become a care-er instead of a chemist. It’s really all about choice, caring and compassion.

            Evidence-based medical and nursing literature is rife with HIGHLY POSITIVE comparisons of NPs to doctors, that include excellent patient outcomes. I suggest you read these studies before you make ignorant comparisons of NPs to LPNs.

  • Doe Gasque

    I am a family nurse practitioner who has been providing primary care in community clinics and Indian Health Services as a locum tenen provider for many years. My patients have wonderful outcomes and we work hard together to treat the underlying cause of their health problems. Personally, I don’t believe in statin, ambien, vicodin or benzo deficiency so my visits focus on things that will make lasting improvements rather than adding ANOTHER pill to the mix. When we practice in this scope, I think we shine.
    Just like the primary care physicians that I have worked with over the years, I refer to the specialist when I need to. I am not prideful. I ask questions. I read, endlessly. I respect the time and effort physicians put into their education. But the vast majority of that time is spent in teaching hospitals dealing with zebras, trauma and acutely ill patients who need a higher level of care. The majority of patients in primary care don’t fit that model. Their child a has a cold and they are worried about pneumonia or the stressed out adult can’t sleep and has fallen victim to the lies told by that moth and wants another pill. For the most part the patients need compassion, education, guidance and support and sadly, that part of the physician education is often lacking.
    I am very good at what I do. I know my scope and my limits. I don’t want to be a physician. This is not a consolation prize for me. I never wanted to go to medical school. I love working in a collaborative environment with physicians. I am not interchangeable with a physician. I always explain that clearly to my patients.
    There is a shortage of primary care providers. We need to work toward solutions and not name calling. It is beneath you. ( BTW, many of us nurse practitioners have IQs more than 2 standard deviations to the right- but that has never helped a patient make healthier choices).

    • kjindal

      so when your diabetic (or s/p MI, or CVA. or LDL=180) patient in an IHS clinic comes to see you for primary care, does he/she NOT get prescribed a statin? Does he just get “compassion” and “education”? And our tax dollars go to the Indian Health Service…

      • Doe Gasque

        Of course they do, but you knew that. But the lipid hypothesis is just part of our discussion. We discuss number needed to treat and number needed to harm. We discuss how much of a role that lifestyle plays in all of this. Angry people are at much higher risk. ( I am sort of worried about you). I am sure that you are well-educated, and a compassionate provider that is more than capable of raising the bar from the lowest form of communication-name calling and personal attacks to offering solutions to the problems we need to overcome in the next few years. We need to move our patients to wellness rather than piling on pills to cover symptoms. We need to improve their SELF management skills. I don’t think any of us can do this in the 10 minute visit.

  • Rebecca

    I have been an NP for 30 years in New England and have seen many changes in health including the ever growing influence of Big Pharma in shaping health policy (with over 30+ full time paid lobbyists on Capitol Hill) and then the HITECH ACT as a result of wasted, spiraling, out of control health care costs gobbling up an unsustainable % of our GDP, which, we can all agree on this point, we can ill afford.
    Come on, let’s all be part of the solution as the professionals we are!
    The bottom line is there are millions of human beings, from newborns to frail elders, in the US with NO access to care, even the most basic services whatsoever. We are facing of a diabesity epidemic, sadly, even in our children, which is over 90% preventable with dire chronic disease co-morbidity consequences in our rapidly aging population.
    Primary health care must “think outside the box”, get creative, and for heaven’s sake get going to solve the daunting problems facing our nation’s health.
    Nursing and medicine can do this better together, than alone. Our patients, families and communities deserve the biest of what both NPs and MDs can provide to improve our public’s health. Shame on us.

  • Bruce Coe

    You all have no idea how comforting it is for this poor potential patient to listen to your bitching and whining. Get over yourselves and do your jobs

  • Allergist

    As a subspecialist in the military, I see the importance of a competent primary care physician in my practice everyday. There are differences in the management style of an average mid-level vs an average family physician vs an average internist. These differences are difficult to measure by true double blinded randomized controlled trials. I have an aging mother with hypertension, diabetes, heart disease, two prior TIAs, hx of GI bleed, and renal insufficiency. I always recommend that she goes to a board certified internist for primary care . Ask yourself this question, who do you want your love one to see?

    • kjindal

      As a board-certified Internist, every single day I am amazed at just how complex some patients can be. And it’s much more than just partitioning their problems into various specialties that get managed by specialists (a tech, or secretary, can do that). I’m thoroughly disappointed that some mid-levels, as exemplified frequently on this blog, are so arrogant as to think they can manage the patient with CHF, CRI, uncontrolled DM, depression, Afib etc. by just referring out to subspecialists and following their orders, or let them “take over”, as another poster stated. There is much more to Internal Medicine than that. And the patient I’m describing is the norm rather than the exception.
      I just took my first IM board recertification exam, since I’m at the 10-yr mark, and it was TOUGH! I know many many cardiologists, gastroenterologists, and other subspecialists that DON’T recert in IM because it’s such a demanding process. For a midlevel to feel equivalent is absurd. And when the above patient walks into their office, I know how they’re managing because I see it often – refer to cardio for Afib/CHF/HTN, endo for DM, renal for the bump in creatinine, etc, then return to “follow-up” (for what???) in 3 months. But this is NOT the proper standard of care, and certainly not cost-effective. Most people (including medicare officials) don’t realize this until it’s too late, and in a few years our elderly medicare patients on 8 meds will not be able to find a board-certified Internist to juggle their problems without shuffling them off rapidly to every specialist under the sun, none of whom speak to their PMD or each other.

      • Allergist

        I agree. Board certification insures that certain criterias are met in order to practice medicine.

        The scariest thing for providers is not knowing what they don’t know. There’s this call that physicians are over trained for primary care. I beg to differ, I say that you can NEVER be over trained for anything. Medical education is a continuing process that doesn’t end with medical school, residency, or board certification. Our patients deserves qualified, well trained providers with specific standards that insure that care is uniform.

        Primary care is extremely difficult. As a subspecialist I do not envy my collegues in primary care. Anyone who thinks that it’s easy shows a certain naiveness that is worrisome. The best providers are those that know their limitation and treat the patient to their best ability.

        • Marquel Tipton PA-C

          I agree. Nicely stated. It’s all about knowing ones limitations.

      • Dayna Gallagher

        Well said.

  • DrDuh

    Shocking… an executive from Big Health suggests that MD’s can be replaced by mid-levels, when said substitution favors his company’s profitability. Really, who could have predicted it?

    The reality is there are lots of decisions that an NP could make successfully and safely in place of an MD. Just as there are many things I can do on my own car. The analogy breaks down when we get to consequences. If I bite off more than I can chew with my car I can get it towed to the shop. If an NP misdiagnoses and the patient stews at home, then I may be called into the ER for an emergent surgery. (Luckily proton pump inhibitors do not successfully mask the symptoms of a slow aorto-ileac dissection)

    Unfortunately, I believe the writing is on the wall and for most people primary care will be taken over by friendly, cheap and generally competent mid-levels. Big business will successfully lobby to remove the requirement for physician supervision. Algorithm-driven ‘cook book’ medicine will prevail. The inevitable mistakes will be written off as the cost of doing business. The people who can afford it will pay for concierge care by actual physicians.

    They used to say that ‘the doctor who treats himself has a fool for a patient’, the new version is ‘the doctor who treats himself has a doctor for a doctor.’ I guess I should count myself lucky.

  • Docbart

    Perhaps AAFP is just right and sincere. Specialists are fully-trained physicians not cut-rate “providers”, usually board-certified in internal medicine. Isn’t that a higher qualification? Sometimes one needs that extra knowledge to recognize that a symptom is not just routine, but needs a higher level of care.

  • Robert


  • Robert

    Hi all:
    Well, I am an NP student. I try to be impartial. I would not comment about physician training, thinking that I know first-hand, because I haven’t gone to med school. Like this, it is inappropriate for another profession to down talk the training, if one will, of another profession, especially if the former haven’t gone through the training of the latter, or vice versa. I believe that NPs have a certain role in healthcare in the USA, but also other countries. For example, in small rural towns in Vietnam, nurse midwives deliver the majority of babies because physicians usually leave for the city to make more money.
    And, that being said as an example, the entire medical monopoly is coming crashing down, and physicians across the US are kicking and screaming all the way down. This is a natural response, but ineffective coping mechanism. Nursing has been primarily female dominated. Medicine mostly male dominated, until around the 1960s. Today, we have a different world than previously experienced. We have generation Y being the most educated generation in US history. And, with these changes, more males are studying nursing, and more females are studying medicine. These are two completely separate, and different, careers, disciplines.
    This is not a matter of quantifying training. It is a matter of many physician societies fighting because they believe that nursing, i.e., advanced practice nursing, is trying to rip off medicine. Who is to say that a general manager is not as good at accounting than an accountant, when the manager has specific training and experience in what one does? Who is to generalize and state that an engineer is not as good as an architect at design? There are plenty of examples of folks with different education and training doing the same jobs. And, that is the case with NPs and physicians.
    The truth of the matter is that NPs are first and foremost nurses. NPs do not try and be like a physician. NPs can legally treat common medical problems that do not typically require the extensive training of a physician and can treat complex problems as a partner with a physician. In my opinion, with all the training that physicians go through, we need them dealing with the complex problems that NPs can’t deal with. And, as a prudent professionals, NPs will refer complex cases to physician counterparts, who, by the way, will bill higher anyway. I personally would not want to go to medical school and all the training to deal with giving annual vaccinations and sore throats. I see that as a waste of time, money, and national resources.
    Think like construction: One can have a 2-year degree and run a construction business, but, more complex jobs require that the contractor call in an architect to certify design/build plans. This is essentially the same thing as referring. Could an architect do the job of the former? Sure. But why would he want to, with all his training?
    I for one believe the entire argument and fighting is so stupid, and it exemplifies the mundane, idiotic, moronic, childish behaviors of the morons in this country who we could do without.

    NPs will win, believe it. The USA with all its technology and know-how could never win a war against China because China is simply too many, too strong. Like this, medicine fighting against nurses is futile. Physicians stole medication prescribing from pharmacists, and now NPs are taking a bit back, as well as pharmacists, to eliminate the medical monopoly.

    • Allergist

      I hope you will learn that primary care is not all about giving “vaccinations and sore throat”. Physicians, pharmacists, nurses, and mid-levels all have roles in the delivery of health care. However, there has to be clear distinctions in responsibilities that is in line with experience and training. Just because you are legally able to practice something doesn’t make it right. My medical license allows me to practice medicine and surgery in my state. Does that mean I can do an appendectomy even though I did an internal medicine residency with an allergy fellowship? Legally, I can. Will any hospital allow me to do so? Probably not. That’s because I am not competent to perform that procedure. You can win recognition by legislation but it takes standardized training to be competent.

      You say that NPs are going to win. What does that mean? NPs are already allowed to practice independently in this country. I respect my mid-level collegues. However, given a choice between a nurse practitioner and a physician; I believe more often than not the general public would choose a physician. Who would you want treating your family?

      • kjindal

        Allergist, so right you are. And how telling is it that Robert, still just a student, is already so indoctrinated into the paranoid propaganda about the “medical monopoly” and the complete misunderstanding of what an Internist does. Imagine how he’ll behave after a couple years of NP school and more propaganda from the “doctor NP” who is “teaching” him how exactly to “stick it to the man” the evil MD who “stole prescribing rights from the pharmacist”!
        I did not have any questions on my medical boards about vaccinations or sore throats. I did, however, have lots on interpreting CSF findings, choice of meds for rapid BP reduction w/acute aortic dissection, diagnosis & treatment of minimal change dz causing nephrosis, etc. Most of the wonderful NPs I work with understand & acknowledge that they would NEVER pass the IM boards, let alone even understand many of the questions. Then there are others like Robert, who, one day, will be treating this nation’s elderly Medicare recipients. Again, so unbelievably arrogant.
        It’s both comical and sad. And what’s with the USA/China analogy???

  • Kristy Sokoloski

    Having read both sides of the issue even more since this blog entry was posted and the comments about NPs going in to Primary Care it led me to some other questions. The first one is this: How many of the NPs that are ready to graduate from school actually want to go in to Primary Care fields such as Family Medicine? The reason I ask this is because one of my classmates wants to be a Nurse Practicioner but she wants to specialize in Diabetes care for both adults and children. My second question is this: Due to the fact that there are a good number of people who have multiple chronic conditions going on how is an NP going to be able to care for them? I ask this because some people who have complicated medical histories due to these multiple chronic conditions are in need of an actual Primary Care Physician and/or specialists to help monitor them because one or all of those conditions could become unstable at any time.

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