Why your nurse practitioner is your friend

A recent editorial in the New York Times about non-physician health care providers or NPPs, has drawn more than 260 comments.  Who are these NPPs and why do so many people care about them?

Historically, nurses have a long history of stepping in when there are gaps.  For example, in the early 1900s anesthesia was given by med students and interns and everybody was unhappy, until nurses started doing it full-time, and then the surgeons were much happier.  When surgeons are happy, everyone is happy, I’ll tell you that for free.

Most of my readers don’t know this, but I was an advanced practice nurse before I went to medical school.  I was one of these NPPs.  The thing about nurse practitioners is that they are trained under a nursing model, not a medical one.  The information is the same, but presented in a much different way.  I can tell you that the training I got in the arts of physical exam and interviewing were at least as good in nursing school as they were in medical school.

Medical school gives you the science background, which is awesome if you are going to study gene therapy or find a cure for cancer.  It doesn’t teach you much about how to take care of patients, which is why you have to do a residency.  Residency teaches you how to take care of diseases and sicknesses, but it’s brutal schedule and the medical milieu take away some of the “taking care of people” part.

Enter the nurses.  I was one.  I can tell you their training.  They have RNs plus usually some years of ICU experience and another 2 years in NP school.  They’re smart.  They know their limits.  They are good a what they do.  They will ask if they don’t know something.

You don’t need neuroscience to take care of people, especially healthy people or people with chronic conditions.  You don’t need a medical degree to take blood pressures, manage medication, give vaccinations, talk to someone about their depression or how sick their mom is.  You don’t need a 5 year residency to diagnose an ear infection or treat a cold.  You just don’t.  And nurse practitioners, by their training in nursing, are much more likely to deal successfully with chronic conditions because they will talk to you and listen to you.  They don’t have the same time-pressures and paperwork blizzards that the doctors have.  They’ve been trained by  nurses, so they think like nurses, not like doctors.  They want to take care of you, not just fix your illness.

If you have a brain tumor that’s not so helpful, but for the vast majority of every-day health concerns, your nurse practitioner is your friend.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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  • http://www.facebook.com/lmpeto Lisa M. Peto

    Thank you! That is exactly true!

  • Oscarthe4th

    While I think the author is largely correct about nurse practitioners I don’t think that she did them any favors here.
    I use a nurse practitioner as my primary health care physiciian. She is very good; she listens carefully; she checks when she doesn’t know. I like her, I trust her, and I am comfortable with her.
    Every so often, however, I think I do see the difference in training, particularly in her knowledge of drugs and potential interactions. It’s been very minor in my case, but I suspect it’s real and might be a problem for some patients at some point.
    MD’s are hardly infallible, and it could be that part of what I perceived was not a weakness so much as an inability to hide a weakness: two radically different things.
    Still, that extra degree of knowledge one gets from advanced training can matter on occasion, even in general practice. To state that it does not matter at all is simply wrong, and set Nurse Practitioners up for a fall by setting too high a bar.

    • karen3

      Oscarth4the, honestly, I would not trust a doctor with drug interactions either. If you have a complicated medication regimen using an online checker and having a good pharmacist who knows her stuff is critical. Pharmacists are not just pill fillers. It’s worth the extra drive if you can find one.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Pharmacists are also capable of making mistakes as well. Even the best pharmacists. We have to be very vigilant about knowing what medicines we are on, and making sure that all doctors that care for us know this as well. This is one reason why my Primary Care Physician wants all the progress notes from all of my doctors to see how I am doing. He also said he wanted to know if I had any complications.

        • http://www.facebook.com/shirie.leng Shirie Leng

          Yes, exactly! It is the job of the patient to keep an accurate list of what they take or get a pharmacist or surrogate to keep the list. It is the job of the primary care giver to figure out if these drugs are appropriate and if they interact, and to get reports from all your OTHER doctors so interactions don’t get missed.

      • buzzkillerjsmith

        Epocrates is a free online database that lets me check drug interactions in a minute or two. Smartphones have it too. Tell your doc if he doesn’t know about it. Easy as pie to solve that problem.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Buzzerkillerjsmith, thanks for the information about that link. Is it something that patients can use as well?

    • http://www.facebook.com/shirie.leng Shirie Leng

      But my point is that you are not going to learn those practical things like drug and drug interactions in medical school. You’ll be taught them but it goes out of your head after the exam. The nurse was taught the same thing. Your doctor has specific knowledge about the drugs he uses every day, but he looks up the other stuff just like anyone else does. I’m not saying that doctors aren’t well trained. I’m just saying that a piece of paper saying they went to school for 4 years doesn’t mean they know what your specific drug regimen means to you personally. That takes experience.

    • buzzkillerjsmith

      Good point. Having a doc or two around to supervise a pool of midlevels is good for the pts and the midlevels both.

  • http://twitter.com/FerkhamPasha Ferkham pasha

    Very true

  • Suzi Q 38

    Finally, a doctor that “gets it” about nurse practitioners.
    We are going to need and utilize more of them.

    What does medicare pay for each patient visit and how many medicare patients do you have to see?

    If you have your own practice, can you afford not to have a NP?

  • ninguem

    Well, let’s look at it another way.

    What things **DO** you need a medical degree to do, or handle, or treat?

    • kjindal

      Nothing at all, by Dr. Leng’s logic. Except I’m sure she will defend the anesthesiologists’ territory as dangerous to hand over to nurses. And maybe radiology.

      • http://www.facebook.com/shirie.leng Shirie Leng

        Nice kjindal! Turns out I think most of what I do can be easily done by nurses. I think it’s ridiculous that nurses can’t give propofol for conscious sedation procedures. There’s no special mysterious knowledge acquired in medical school that gives you the privilege of administering propofol. That is a policy issue and frankly, probably a financial issue, coming from the powers that be. Take my territory – you’re welcome to it. I’ll back you up. PS we hate radiology. You can have it.

        • ninguem

          Fine, let the CRNA’s bill independently, you can bill for your services only when needed.

    • http://www.facebook.com/shirie.leng Shirie Leng

      Good question ninguem. Maybe I’m suggesting that the doctors role should be more supervisory, a back-up and resource for those seeing patients with seemingly basic problems who may have something more going on. Certainly with my CRNA’s, whom I love, I leave them pretty much alone to do their work unless there is something unusual or concerning, or something that occurs intraoperatively that they need help with.

  • Ray

    “And nurse practitioners, by their training in nursing, are much more likely to deal successfully with chronic conditions because they will talk to you and listen to you.” I’m not sure what on basis or data this statement is being made, but I have a very hard time believing this blanket statement, in addition to “They want to take care of you, not just fix your illness.” While it’s true some docs my carry the attitude, I believe most docs do talk to their patients and want to take care of them, particularly Family Med docs and Internists, the most comparable group to NPs.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      I haven’t found that to be true at all. I am an family doc, I spend more time with my patients that most NP’s I know. Also most NP’s today spend only the minimum time in practice (usually the ICU) before going back for an NP degree. I know very few NP’s that had significant clinical experience.

      • mike mayer

        Beau, i might have to agree with you on this one. I was an RN with an ADN for 20 years before i went back to school to get my BSN and now my MSN and i may finances permitting get an NP degree. I have seen many things over the years that the 25 year old PA or NP just cannot have experienced. I think the assembly line attitude to push out RN`s with an MSN that have never had more than school clinical experience may not be a good one. Again, i am old fashioned i suppose.

        • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

          Exactly. I would love to hire an NP by the end of the year and will be looking particularly for one with more clinical experience as a nurse (5-10 years).

    • http://www.facebook.com/shirie.leng Shirie Leng

      See my comments to Dr. Jain. It wasn’t my intention to say that doctors don’t do these things. Only that the NP can provide some of it so that the doctor can concentrate elsewhere. It seems I have insulted a lot of good doctors unintentionally.

    • Trudi

      I am a patient with a chronic disease and my Specialists generally spend more time with me and talk and listen to me more than the PA’s or NP’s that I have. But I’m sure it goes the other way around in many cases. I think it’s pretty individual and the stereotypes of who spends more time and is more caring don’t hold up in my experience. I’ve also heard that female docs are more empathetic. Well, I am a female and my one female specialist is much colder than my male doc’s — so go figure.

  • kjindal

    just curious Dr. Leng,
    how do you feel about CRNAs, and specifically their suitability at independent practice of anesthesiology? By their training under the nursing model, are they more suited to follow a treatment protocol than an MD?
    thanks

    • http://www.facebook.com/shirie.leng Shirie Leng

      Interesting point about NPs in specialties. I kind of agree with you on this. It’s like anything else; if you do the same thing and see the same thing over and over, you become a little bit of an expert in that thing. I know some neurology NPs, for example, that do neuro exams better than neurologists, because they do it every day and have the time to do it thoroughly. Absolutely those nurses are extremely valuable and should be used as adjuncts and assistants to the neurologist/neurosurgeon. I’m not suggesting that doctors are useless, only that the extenders can really know what they are doing. Appreciate the discussion.

      • kjindal

        Sorry but that is a trivial point. A 3rd-year medical student on a neurology rotation can master the bedside neuro exam in a couple of days by seeing 6 or 7 patients on a consultation service. But that doesn’t mean that he can replace the neurologist in making management decisions. And tell me who, in the United States, is going to use the bedside neuro exam to replace imaging in pinpointing a diagnosis?
        And as far as “your” CRNAs, what if they were independent completely, and you were only paid upon their consulting you for that 1/100 case that wasn’t routine? If you’re passing gas on mostly healthy 40-somethings for minor elective procedures, endoscopy, etc., then you completely do not understand the typical Internist whose everday routine patient is medicare-age, on ACE-I, statin, beta-blocker, SSRI, etc., and sees 6 different specialists, none of whom communicate with you.

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        I’m sure you love your CRNAs. I love them too! In fact I think they are just as good as you are and you should be replaced!

        Why should we pay you 400k when a CRNA can do exactly the same job for 150k?

        Your hospital should fire all the anestheiologists and replace them with CRNAs.

  • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

    I’m amused that Leng states that primary care duties can be easily handled by a nurse, but yet she leaves out her own specialty as if CRNAs are not qualified to manage anesthesia.

    So Leng I have a question for you — are you being purposefully obtuse or are you just ignoring the studies showing that CRNAs are just as good at managing anesthesia as anesthesiologists are?

    A primary care NP makes about 80% of what an MD gets. Anesthesiologists on the other hand, make TRIPLE what a CRNA does. So I would argue that we’d save a lot more money by having CRNAs take over and kick the MDs out of anesthesia.

    What say you, Dr Leng?

    • Cheryl Wicker

      “A primary care NP makes about 80% of what an MD gets.”
      Not really true in any salary studies I have looked ar. In my area, primary care NP’s make about 1/2 of what the primary MD’s do.

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        That has been my impression as well about 50-60% in the primary care fields. In my opinion, most are underpaid as well. If seeing the same volume of patients I would hope they would pull in more like 75-80%. By and large, most providers who utilize NP/PA’s use them for acute visits and simple follow-ups while leaving new patients and complicated patients to the MD/DO’s. I think its an idea model but it doesn’t allow for much new learning exposure for the NP, which is a shame.

  • buzzkillerjsmith

    The author is probably right. Much of what I do could be done by someone with much less training. I taught a med student how to freeze warts yesterday. Not he’s competent at it.

    What is the comparative advantage of doctors? Probably in managing complex interacting illnesses or in diagnosing unusual illnesses. I suspect the migration of med students into these activities will continue. We’ll need fewer primary care docs, except as outpatient consultants for the midlevels, and, frankly, we’ll need fewer anesthesiologists, most of whose cases are pedestrian.

    A lower need for docs is assuming that there will be enough midlevels to handle the workload, a very big assumption in primary care. Midlevels aren’t dumb and they too realize that primary care is no bed of roses. But for a doc, managing stable HTN, DM, dyslipidemia, etc., is essentially brainrot. Med students would be wise to avoid it.

    • Suzi Q 38

      FP and PCP’s are always going to be needed.
      I hope that we can get more back into medicine.
      My BIL had an FP that continually misdiagnosed his pancreatic cancer for a chronic backache.
      By the time that he received any sort of scan or diagnostic test, he was in the E.R., doubling over in intense pain.

      His doctor had treated him for back pain for 6-8 months prior.
      You wonder at what point in time would she say, “Wow! You are asking for a lot of Norco, or maybe we should get an MRI…”
      She never did. He could barely get out of bed.
      By the time he was diagnosed by a general surgeon that the E,R physician called, he had mets to more than a few places and sadly died within 2 months. He was only 52.

      Not that his outcome would have been different, but Steve Jobs lasted several years with the right treatment.

      My point is that even the doctors ignore obvious signs and accidentally withhold much needed treatment that could have prolonged life. Or in my BIL’s, he did not receive the right treatment or a diagnosis at all. He had to “declare himself” as his PCP wasn’t doing that by driving himself to the nearest E.R.

      I am sure that if my story involved an NP, people would say:
      “This is why you don’t shouldn’t use NP’s.”
      Maybe the NP would have asked the right questions.
      You never know.

  • http://twitter.com/AtulJainMD Atul Jain, MD

    An interesting post. I agree that nurse practitioners are a vital resource, especially in an era of severe health care access issues and primary care shortages. In my experience I have found them to fill a much-needed role in the patient care team and to improve patient care in a collaborative manner. I really hope that with the Affordable Care Act rollout nurse practitioners will be able to help reduce the impending primary care gap.

    On the other hand, as a primary care physician, I find your comments regarding the scope of primary care practice offensive and your overall opinion of medical school curriculum quite reductive. Yes, I do see plenty of back pain, headaches, earaches and what have you. And, yes, oftentimes the treatment for these issues remains the same from patient to patient. But what I offer is more than a rote approach to common illnesses. I am trained to provide a level of expertise which allows me to discern the serious health issues that masquerade as common and benign illnesses. I’m trained to formulate a differential diagnosis for both simple and complex illnesses and create a tailored management plan that is cost conscious and is respective of my patient’s preferences. I also use my training on a daily basis in providing patient education, such as why I feel prescribing antibiotics for the common cold is harmful to the patient and contributes to the development of drug resistant strains of bacteria.

    My sense of despair was heightened when I saw that you are an anesthesiologist. I really hope most specialists do not share your feelings about primary care physicians. I also really hope that your experience with physician extenders in the fields of surgery and anesthesiology can be translated to primary care practice- it most definitely can not. To quote a tired cliché, that would be like “comparing apples to oranges.”

    Atul Jain, MD, MS
    Assistant Professor of Medicine
    The University of Chicago

    • http://twitter.com/Clinician1 Dave Mittman, PA

      Atul: Without trying to convince you, I would ask that you work with a PA or NP who has ten years experience in their specialty. Work with people who were trained in family medicine. I was. I managed complex cases. I enjoyed learning as much as I could. I was lucky to work with physicians who looked at me as a peer.
      Do you really think three year med schools will be that much different than good PA programs? If you do, you are fooling yourself. I was a medic before PA training. Imagine an independent duty medic with superior training coming back from Afghanistan , having all their pre-med finished, then going to school for 27 straight months. Then a residency. Then coming out. Not shabby and still learning.
      Sorry, you were allowed to practice as far as your brain took you. Allow the same for all others ask.
      Dave

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        Its not the three years of medical school (although that is one difference). Its the three years of Residency experience. Two more that NP’s or PA’s that make the difference. I know several very good PA’s and NP’s. But I know a far larger quantity of poor ones. An instructor of mine use to say that a resident, having just completed an internship, has learned how to treat a cold and kill a patient quiet well. It takes the other two years to learn how to save one. I feel PA’s and NP are a vital cog in the medical realm but those that put themselves on par with a board certified physician (especially early in their career) are kidding themselves and their patients. They are the ones I dislike.

    • http://www.facebook.com/Kate.Ackers Kate Ackers

      Dr. Jain,

      I am a student in the Family Nurse Practitioner Doctoral Program at the University of Washington. I too am trained to provide a level of expertise which allows me to discern the serious health issues that masquerade as common and benign illnesses. I’m trained to formulate a differential diagnosis for both simple and complex illnesses and create a tailored management plan that is cost conscious and is respective of my patient’s preferences. I also use my training on a daily basis in providing patient education, such as why I feel prescribing antibiotics for the common cold is harmful to the patient and contributes to the development of drug resistant strains of bacteria.

      Nurse Practitioners provide cost-effective, holistic care that satisfies our patients.
      Thanks
      Kate Ackers, RN, ARNP student
      University of Washington

      • http://www.facebook.com/hcberkowitz Howard C. Berkowitz

        Again, I freely admit I may be an outlier in my dealings with NPs. It’s not always a matter of what I see as the nursing model, with a preference to educate patients. Rather than be told that I should not get antibiotics for the common cold, I struggled with one NP, who first threatened no treatment unless I complied with some non-critical lab requests, and then prescribed what I considered a suboptimal antibiotic for severe cellulitis, along with totally inappropriate pain control. Especially if she had accepted some of my abilities and let me start self-administered parenteral antibiotics, I might have saved five days of ever-increasing pain and shuttles to the ER, and four days of hospitalization.

        Unfortunately, I tend to find that NPs are threatened by insistence on a pathologic diagnosis, and challenges, on scientific grounds, of treatment recommendations. It amazed me, if “enabling” was a goal of holistic planning, that a NP managing my diabetes, in a specialized hospital, refused to consider my regimens for glucose measurement, insulin adjustment, and injection sites. She became quite angry and insisted that she would decide the plan and didn’t welcome my input.

        I rarely have such problems with physicians, because we seem to communicate, far earlier, on a peer basis.

  • Guest

    Thank you, Dr. Leng for supporting NP’s! I’m an NP working in an Internal Medicine office. I’ve been an NP for 18 years and a nurse for 12 years prior to that. I love what I do and I’m good at it. I see patients just like the internal med doc in the practice in which I work. When I have concerns or questions, I go to him. When he sees something I might do differently he comes to me and we talk. I’ll do the same with him, and yes, I do find things he’s missed. It’s a team approach. We share interesting cases and learn from each other. It’s all about “good patient care.” Yes, he has more medical education than I do but I have my own set of strengths and a good patient following. We both have our strengths and weaknesses, work very well together and respect each other. Some NP’s/PA’s are good and some not. The same can be said of physicians. Find someone you can relate to and who seems knowledgable but still knows their limits. And lastly, medicine these days is a team approach, and a huge part of that team is the patient.

  • Gasman

    I dont think any professional in the medical community i mean doctors- view NP as an enemy. Likewise for CRNAs. However, what physicians hate is the blurring of the lines between medical professionals. Are nurses smart and intelligent? Are they hardworking? yes!!! they all do. However, to start saying that NPs or CRNAs can just act as physicians and do their job sets a dangerous note. Is that going to happen? yes you bet. to cut costs thats the only way.

    However, I want ask Dr Leng something? If her state governor showed for surgery does she put more presence in the room? if a senator or a congresman or a big donor to the hospital or a donor’s daughter comes for surgery do they demand an MD? if her department goes all crazy to accomadate (which is what likely will happen) why are they doing it. Get the CRNA to do it as they are just as good right??? that never happens.All this talk is a sham to fool the common man- when the elite want their care there are different rules, different standards and different game plan.

    Dr Leng we physicians never look down on nurses or nps or crnas. stop this needless lecturing.

  • jeo

    “They’re smart. They know their limits. They are good a what they do. They will ask if they don’t know something.” For the most part, I agree with this. I wish I could say the same for the primary care physicians I work with.

    As a specialty NP – 11 years working in endocrinology with about 90% of that diabetes – I am constantly amazed at physicians who do not recognize what they don’t know. Although it is most obvious with them, I do not limit this to MDs by any means – I honestly think it’s a primary care and hospitalist problem and I see it with NPs and PAs as well. I believe that our monetary based medical system is making it important that there are fewer visits and fewer referrals, that less time is taken with really understanding what is going on with each patient, and that EHRs have actually made it far more difficult/time consuming to see the overall picture.

    I do think there is power in the terms we use. Post-graduate education is always about socialization into a profession as well as the acquisition of specialized knowledge. Physicians are “trained” into their positions and are meant to believe that their medical knowledge is pretty much all encompassing truth (within the bounds of current knowledge). Nurses are “educated”, and the idea of not knowing everything is integral to the nursing knowledge base.

    I have no interest in pitting one against the other. I want to point out that we ALL need to truly recognize the limits of our knowledge and use each other (as well as all of the other health care professionals that we work with) to give the best care possible to the people who trust us to know what we’re doing.

    • kjindal

      sorry to burst your bubble, but practicing primary care internal medicine is MUCH MUCH more complicated than treating diabetes as an endocrine consult. By the time they’ve made it to your boss, they’ve likely already been tried on various oral hypoglycemics +/- insulin regimens (unless their primary is an NP who just refers out for everything, which I see all the time). The vast majority of diabetics never ever see an endocrinologist, and are managed by their PMD, who is also managing their CAD, HTN, BPH, HLD, depression, and everything else the VIP specialist is too self-important to bother with.

  • http://www.facebook.com/hcberkowitz Howard C. Berkowitz

    I’ve been keeping track of my encounters with different NPs, and I’m afraid that the most successful was simply to get a good look at an acute burn and an appropriate prescription. This article, though, is useful in helping me formulate why I do _not_ want to see NPs: I will handle my own chronic conditions and lifestyle adjustments. What I want from a clinician is a pathological diagnosis, and seriously interactive discussion on treatment plans. Yes, I have a good deal of medical knowledge that may make me an outlier.

  • Cheryl Wicker

    Good perspective on the differences between medical and nursing models of care. But this: “They don’t have the same time-pressures and paperwork blizzards that the doctors have,” has never been true in my 18 years of NP experience in primary care. I am expected to manage my panel of patients, see the same numbers, and chart accordingly.

  • Nancy Onyett, FNP-C

    This article has daunted me since I read it on Twitter. In health care today, there is still a lack of knowledge in the NP scope of practice by patients and many physicians. I found this article to be written in a tone that nurse practitioners are trained from a “nursing model” and not a “science model”. I disagree with this language because it is not well explained. The first two years are didactic curriculum. Nursing theory is one small part of this only because it is leading to an advanced degree in nursing either at the master or Ph.D level. The curriculum is heavily science based with acute and chronic diseases, etiology, pathophysiology, pharmacology, diagnosing and treatment. Without the science, there wouldn’t be any evidenced-based medicine guidelines that physicians and NP’s alike are expected to know and follow. NP boards are written with application of the science to the conditions in the track the person is trained in The board exam licenses NP’s in their state. In the certification exam an Acute Care NP would not be taking the same certification exam as the FNP. In family practice, the requirements were around a 1000 hours in practice and being a graduate from an accredited university with the curriculum satisfying the family nurse practitioner certification requirements.
    I find the article to be undermining the education of NP’s. The tracks available are ACNP, ANP, FNP, PNP, Neonatal NP, WHNP and PsychNP. Each one of these tracks have a different focus and criteria for their curriculum to be met to graduate and sit for the board exam.
    I am a FNP-C, family nurse practitioner, certified. My didactic curriculum focused on family medicine, the preceptors I had were mainly physicians per my choice. In my area of family medicine I am able to see and treat all health problems from birth to death, that I am trained to do. However, if someone needs specialty care then they are referred out. I do simple office surgical procedures along with treating complexes diseases at the family practice level. For example if I worked up a patient for an autoimmune disorder and I diagnosed Lupus, I would refer to a Rheumatologist for further treatment.
    My point is whatever track the NP is certified in we are doing a lot more than just seeing upper respiratory infections as this article is suggesting.
    Lastly, I don’t understand what this writer means by “friend”. It is demeaning in that we are not trained at a higher level. First, there is the established Np/patient medical/legal relationship not a “friend”. We are trained professionals to treat the acute and chronic conditions for patients per our specialty. In family practice patients who walk through the door we are trained under evidence-based medicine guidelines not a so called “Nurse Model”.
    In family practice, I see 30 or more a day on a busy day and about 25 on a less busy day. Acute Care NP’s are rounding in hospitals and the office seeing high volumes of patients or they are working in a busy ED seeing a high volume of patients a day. We have just as much responsibility on our licensing to follow through with paper work and EHR as physicians do with their licensing. Licensing is totally separate and depending upon the state the NP can either work independently as we are trained to do in family medicine or work under a physician such as a specialty in pulmonary cardiology in the adult acute care track. Each track is different and I cannot speak for their limits since I was trained in the family track.
    Many NP’s branch out in training such as I did in hormones for men and women. Many of my patients improve with their chronic condition once their hormones are balanced. I found this training very valuable with the obesity and metabolic syndrome that we see without recourse.
    Every practitioner whether it be a physician or NP is accountable for that patient’s care at a professional level not as a friend. Have I made myself clear?

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      1000 hours of practice. A typical Family doctor completes that much clinical time in residency before they hit the 6 month mark of their 3 year residency.

      • crnp2001

        What everyone conveniently FORGETS is the number of years and clinical hours of practice that we get while obtaining the Bachelor of Science degree in Nursing…PLUS working as a BSN while going to school for the Masters degree/FNP, etc. The average time that an NP candidate has worked PRIOR to applying for graduate school is at least 10 years. So…working 10 years as a nurse…then going back to graduate school. Hmmm…the 1000 hours of clinical hours required is ON TOP OF working hours already obtained.

    • Tania

      Everyone Forgot CNMs

  • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

    The danger is that practitioners that are not physicians are routinely having primary contact with patients. That will happen with increasingly frequency as we move into ObamaCare. It simply is not economically possible for a physician to see the patient at every visit. As cancer patient, I rarely see the oncologist. I see an NP. I like and trust her.

    But, something is missing when there is a breakdown of the physician-patient relationship. The NP is not an oncologist. I know that the cancer center is trying to move me in and out. I can’t help but feel like a bother. I try to be as quiet as possible while the NP examines me. I don’t ask the NP medical questions because she is not an oncologist.

    I can’t help but believe that there is a problem with the healthcare system when there is no physician-patient relationship.

  • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

    Dr. Jain – excellent points.

  • http://www.facebook.com/shirie.leng Shirie Leng

    Jason- thanks for the comments. You are actually wrong. I was an NP before I went to medical school. I had a bachelors degree and a masters degree. From Yale.

  • http://www.facebook.com/shirie.leng Shirie Leng

    Dr. Jain- thanks for your comments. I am very sorry if you were insulted. That was not my intention at all. Primary care docs are well trained and provide great patient education and definitely work in a manner that is respectful of patients wishes. In a perfect world every patient would have access to a doctor such as yourself whenever they wished and for as long as they wished. There would be no need for NPs and Pas. But that is not the world we live in. All I’m suggesting is that the NP can provide some of the things you also do, freeing you to deal with the more complex patients and problems. That’s ALL I’m saying.

    • http://twitter.com/AtulJainMD Atul Jain, MD

      Thank you for clarifying, Dr. Leng (and my apologies for misspelling your name… just caught my mistake)

  • http://twitter.com/HealthExec Robert Stone

    This is a great piece … as far as it goes. The “top of license” concept makes all kinds of sense and is going to be a major contributor to actual reorganization of the system under ongoing reform. I would point out, however, that for many of the activities, described, Nurse Practitioners are overkill from a required skills perspective. Top of License criteria need to be developed for each class of health professional and, in some cases even non-professional personnel. There are many activities that we expect patients to carryout for themselves — think self-blood glucose testing, for example — which suggests that there are many activities which require no professional degree, merely competent training. In fact, the evidence would suggest that a competently trained technician who does a limited number of related activities will probably be more competent than a higher level professional who only does those activities rarely.