Increasing the role of nurse practitioners in the inpatient setting

We are fortunate in our country to have the best medical technology in the world. Unfortunately, delivery of this technology, reflected in a worldwide healthcare ranking of 37th, is a disservice to the American people and must be rectified especially when Cuba is ranked 39th.

As provisions of the Affordable Care Act are put in place, a daunting factor is the shortage of doctors who will be needed to provide this healthcare. Statistics from the Association of American Medical Colleges predicts by 2015, we will lack 62,900 physicians nationwide, and this will grow to 130,000 by 2025. This is a dilemma that cannot be quickly nor easily remedied, as it will take decades to catch up. What can be done until then?

We must harness present available resources including nurse practitioners (NP) and physician assistants (PA) to bridge the healthcare gap. Integrating NP and PA expertise is imperative, but this must be done while assuring quality patient care and not bring the American healthcare ranking even lower.

As a member of the Medical Executive Committee (MEC) and Chairman of the Department of Medicine at our small community hospital, I have studied these details and would like to convey to you my findings. Our hospital is not presently considering PAs for staff membership, therefore I will restrict this discussion to NPs.

A nurse practitioner is a registered nurse (RN) who has completed graduate-level education 1-2 years beyond their degree, with some even specializing in fields like pediatrics. Typically, they provide primary care in an outpatient setting like a clinic or medical office under the supervision of a doctor. For years, qualified RNs have moved forward attaining an advanced degree as a NP allowing better and complete care to our patients. So what is the problem?

Hospital administrators now want NPs to take care of inpatients, but obviously, these patients are much sicker than those who are outpatient. NPs rarely get training in a hospital setting, and prior to their post-graduate degree, RNs are taught to follow and implement physician orders, not to develop nor manage a medical care plan.

I trained in a hospital starting my first year in medical school, and this continued through surgical and medicine programs for the ensuing 10 years. My recognition and ability to treat acutely ill inpatients allows strategy development from the initial history and physical resulting in a treatment plan, and then management of that patient during their hospital stay. NPs are fully capable of this intellectually, but it must be rigorously taught in a hospital setting to assure quality and perfection. They do not have these initial qualifications, but should they be restricted from a hospital inpatient setting? I do not believe so, as long as adequate training and oversight is maintained.

The State of California regulates the “scope of practice” for NPs as legislation is not at the federal level. Some of these rules though sit in a “gray zone” and hence there is tugging by special interest for doctors from the California Medical Association, nurses from the Board of Registered Nursing, and administrators from the California Hospital Association.

In order to allow NPs to provide patient care in a hospital, by State law, a Committee on Interdisciplinary Practice (CIDP) must be established. My hospital did this, but the hospital administration asserted control over this committee by recently having the Board of Directors change a hospital-wide policy removing it from the auspices of doctors. Consequently, the physician chairperson was replaced by an administrator, and this has been surreptitiously done at other hospitals as well.

With the CIDP no longer a physician committee, I must be careful not to divulge confidential information. Suffice it to say, problems faced by other similarly changed outside hospital committees are: oversight credentialing and proctoring of NPs is not by the medical staff but instead by the administration CIDP; there is no physician committee peer review of NPs; and NPs are hospital employees.
This last problem is fearfully disturbing as NPs might be financially coerced into discharging patients too early at the behest of the administration. No doubt this will especially effect our elder senior patients.

Wherever you live, your local hospital may now be implementing programs using personnel not scrutinized by physicians. The healthcare rendered to you or your loved one might therefore be substandard and lead to undesirable complications. As Americans, this should be where we start tugging our special interest.

The doctor shortage will have a profound effect on every community attempting to receive adequate medical care. Using existing resources like NPs will bridge the healthcare gap, but this must be done wisely and carefully to assure patient care is not compromised.
California and other state legislators must be made aware of this problem and strictly define the rules between outpatient and inpatient care, as there is clearly a difference in acuity and intensity of illness. Ultimately, any legislation concerning acutely ill patients cared for by NPs must lean toward scrutiny by well-trained medical doctors, and not hospital administrators.

Should we see this happen, you might expect our worldwide healthcare ranking to improve.

Gene Uzawa Dorio is an internal medicine physician.

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  • trinu

    So it’s not enough to just shunt people off to midlevels and keep them away from their doctors in the outpatient setting with the “patient centered” medical home. Now, apparently you want it in the hospital too.

    • Mandy

      I’m only half-joking when I say that I see a future where better-off patients or their families slip the hospital administrator a cash-filled envelope to guarantee treatment only by real doctors.

      • Guest

        They call that a 2 tier system in other countries, and frankly I don’t have a problem with it. Something in place for everyone, better quality for those with cash.

        • bill10526

          It is good to see someone brave enough to say what you say, although you use the guest monicker. .

          As i understand the literature, there is no discernible difference in quality within board certified groups. That came home to me when I visited my friend in a small hospital in Peekskill. He was zapped seven times and had a complicated bypass surgery. I expected to find him in the critical care unit loaded with tubes and lines. He was sitting up in a chair, and he and my wife drove me to distraction with talk of real estate. Mayor Koch bragged of his care in one of the best hospitals in the world, but his results, miraculous to him, were no better than my friend’s results.

          The other example. My wife needed a physical for her job. Just by chance she was assigned to one of best doctors in the world. But he had a deuce of a time getting the form right.

          As a very smart pension actuary, I found that I solved an actual problem about once a year. Almost all my work was routine. I suspect that is true with most doctors most of the time.

      • LastoftheZucchiniFlowers

        I am not joking at ALL when I remind you that this has been going on for a long time at places like Cedar’s Sinai; only the patients are funding endowments, chairs, grants, new wings., equipment, etc., in exchange for ‘the best’ doctors. Conversely, wallet biopsies have landed some unfortunates in substandard (but not necessarily only physician) care. The author, however, does not decry NP/PA inpatient care on its own merit, only that as employees of a hospital system these providers might be beholden to a group which might not have the patients’ best interest at heart.
        Finally, read your state’s physician licensing sanctions on any given day. You will come away amazed and horrified at what some ‘real doctors’ are doing.

        • Guest

          Wallet biopsies unfortunately lead some patients to have unnecessary procedures…simply because they can pay. This may be argued to be substandard care as with increased intervention comes increased risk of complications.

          I fully agree that there are some unscrupulous physicians out there trying to scrape any dollar they can from the patient or insurer, many times unethically.

  • disqus_qJEMXTKtR1

    Presently, it is inevitable American healthcare will need drastic changes to sustain outpatient and inpatient care. The best solution is to produce more doctors, but this could easily take a decade.

    With the unscrupulous business takeover of the medical profession, paying less to midlevel practitioners allows for greater profit. This is the story behind the story the public should be aware of.

    Our responsibility as nurses and physicians must be to safeguard patient care and quality, and not allow business people sole oversight of providers. The reality is our role now is limited, but we must re-establish our input and decision-making assuring standards are maintained. Will the public agree with us, and legislators provide the backup? If not, a “cash-filled” envelope as Mandy pointed out might be the only influence the public will have.

    Not stated in the article: our hospital CEO is also the Chairman of the California Hospital Association. This is the battle we are fighting.

    Gene Uzawa Dorio, M.D.

    • Ian

      At the moment things are moving in the opposite direction. California wants to let unsupervised optometrists and pharmacists manage chronic health conditions.

      http://articles.latimes.com/2013/feb/09/local/la-me-doctors-20130210

      In the state of Oregon PA and NP pay being equalized with physician pay has passed the state house.

      http://www.thelundreport.org/resource/nurse_practitioner_pay_equity_easily_passes_house

      I fear the envelope to see a real doctor is the far more likely scenario (well actually a two tiered system of crappy government sponsored insurance, and patient’s with money/private insurance).

    • Guest

      Very well said and I agree with Ian, we are moving rapidly in the opposite direction to protect the profits of special interests’ groups. As a potential patient I fear for the future of health care and will do anything and everything possible NOT to become a patient.

  • Rachel Prewitt

    I am 4 months away from completing my (3-year) graduate NP education, and articles like this make my teeth hurt. The main problem presented by the author is that NPs are not trained to take care of hospitalized patients. A little bit of research would reveal that this is not true. NPs may specialize in primary care OR acute care. Acute care NPs (pediatric or adult) are specifically trained to care for –you guessed it– acutely ill patients. This training largely takes place in hospitals, and is worlds away from “following physician’s orders.”

    I cannot take any article about midlevel providers seriously when it is so clear they do not take the time to know just what they are talking about.

    • Close Call

      Thanks for your input. One thing that causes this fear is that most of us don’t really know what NP training entails.

      By the time a family medicine resident graduates, they have to see X number of clinic patients, have to have had done X number of deliveries, procedures, didactics, EKG interpretation, nursing home visits, X number of patients carried on an inpatient service. In the future, the ACGME will want more detailed reporting of number of types of patients (i.e. diabetics treated, etc). So it’s not just doing 3 years of residency, it’s about how much experience you got in that residency.

      I’m curious to know the national standards for NP training. How many patients are you required to see before you’re allowed to graduate? How many procedures are required? What’s the minimum number of patients you’re required to carry on an inpatient service and for how long? Is there a place to view these things?

    • Guest

      So exactly how many hours of clinical experience do you get prior to receiving your diploma? Do you do a residency? Do you honestly feel that once you graduate you will be clinically competent enough to take care of patients in the “real world” on your own without a physician’s supervision?

    • anon

      LOL!

      You’re suggesting that those ~500 clinical hours of “training” (ie. shadowing) are enough to practice inpatient medicine independently? Jesus. I got more hours of training than that during the first couple of months of my 3rd year of medical school — I had 5 more years of training after that!

      By the time I was trusted enough to practice independently, I accrued almost 20,000 hours of rigorous training. When did it get to the point where 500 hours was “good enough”? Or ~1500 hours with a DNP program? It seems that NPs and DNPs want to skip all the hard-work.

      It takes a lot of hard work and sacrifice to get the privilege of practicing medicine independently. There are no shortcuts (except, of course, if you have a ridiculously powerful lobby like the AANP). While we spend ungodly hours on learning the basic sciences and the clinical practice of medicine in med school and residency, these nursing midlevels learn how to become more politically active and push their agenda of having independent practice in all states. Seriously. Look at their curricula and see how much actual physiology/pathophysiology they learn — it’s next to nothing!

      The best NPs/DNPs I’ve ever seen (I’m an attending now) function somewhere around the level of a late-year intern. The difference is that interns can do more than pattern recognition, whereas the midlevels can only work with pattern recognition and, once something presents weirdly, they don’t know what to do. Haha, we had our 4th year med students on their sub-I’s helping the “experienced” nursing midlevels come up with proper assessments and plans for their patients — how pathetic! Some of the NP students (who’ll be graduating and practicing independently in a few, short months) couldn’t tell the difference between Gram negative and Gram positive bacteria and couldn’t understand why that distinction is important! I believe the exact words one of them used were “who cares what those stupid bugs look like under the microscope?!” I pray for their future patients. This is something I would be shocked if M1s didn’t know…

      PS. The PAs are absolutely awesome! Great to have around. They actually have a medical knowledge base (since they don’t spend most of their training learning how to be politically active and learn actual, useful medicine instead). I’ve got nothing but good things to say about PAs and their training. Keep up the awesome work guys!

      • Rachel Prewitt

        “You’re suggesting that those ~500 clinical hours of “training” (ie.
        shadowing) are enough to practice inpatient medicine independently?”

        1. It’s not shadowing, and it’s not ~500 hours in any programs that I’m familiar with.

        2. No, I’m not. I’m not yet aware of a state that permits ACNPs to practice independent inpatient medicine. My exact words were, “specifically trained to care for acutely ill patients.” I was merely pointing out that there are NPs who are trained separately from primary, family practice. FNPs will rarely be the ones you see in the inpatient setting. All the ACNPs I know work in collaboration with physicians.

        3. It’s a good thing you posted anonymously. Your disrespectful tone brings shame upon YOUR profession.
        4. There are NP students who don’t know things that you think are important? Okay. There are MDs who don’t know things that I think are important. Neither your examples or mine disqualify everyone within the field from what they are doing.
        5. I have spent zero hours of my training learning how to be politically active. You brought that in. I along with other NPs have a “medical knowledge base” as well. It’s unfortunate that you have had a bad experience with NPs but it is in fact the case that there are things that go on outside of your (apparently very small) corner of the world.

        • Guest

          You did not answer Close Call’s questions regarding requirements prior to your completion of your program. Many of us are legitimately curious.

      • Theresa Bubenzer

        Someone has had a bad experience with nurses, I think. The requirements for an ARNP are a 4 year degree in nursing, two years clinical experience as an RN, and a two year Master’s degree. The requirements for a PA are a 4 year degree in any subject, could be music, or history, and a two year course of study. There is some difference in training and perspective, but it does not involve politics. Remarks that you are making are inflammatory at best and serve no one but your ego’s need to brunt about disinformation.

      • Guest

        Sorry, I haven’t found PAs to be any more competent than NPs. Both are perfectly acceptable when supervised, incapable when practicing solo. It seems they know how to diagnose and treat according to the textbook, but they don’t understand how things might not be practical in real life. Thanks to residency physicians get a lot of practical information in a short amount of time. The NPs and PAs, lacking that, require decades of practice to approximate the level of competence of a new grad.

    • Suzi Q 38

      Rachel,
      My daughter has a Master’s in nursing and works at the ER of a fairly busy, first tier hospital.
      She is working on getting her NP, all the while accruing patient experience along the way. I think some of these patients are acutely ill, not sure.

  • disqus_qJEMXTKtR1

    Certainly Rachel Prewitt, I could be wrong about training of NPs in a hospital, but in many years of practice and multiple associated hospitals, I have never seen them being trained in this setting. Having researched California hospitals and NPs, I found a dearth of available hospital NP training programs.

    If a NP is to practice in a hospital setting, then they should have training in that setting. Augmenting this availability is paramount in shoring up our healthcare system.

    The point of the article is to make sure NPs are appropriately credentialed and have proper oversight with their hospital activities and privileges subject to physician peer review, not just by hospital Administrators.

    Gene Uzawa Dorio, M.D.

    • Rachel Prewitt

      I can only speak for my own university-based program–and probably a few in the surrounding area. However, the Acute Care Nurse Practitioner is a national certification from the ANCC and is especially tailored toward the care of hospitalized patients. Students such as myself undergo university-based education in combination with clinical preceptorships. It is dissimilar to a residency in that the hospital itself is not providing the education, but merely the educational setting. In order for a student around here to see patients as an NP student in a hospital, there must be an educational contract in place with the university. Some hospitals are more amenable than others to hosting students.

      • W.B.

        Is it more like the student practice of “shadowing” a real doctor then, than actually being a resident?

        • Rachel Prewitt

          Ideally, no. Could NP students get away with doing nothing but shadowing for most of their clinical hours? Probably. But the ideal clinical experience for an NP student is quite similar to a residency as I know it. I round on patients, perform consultations, develop diagnosis and treatment plans, all that–and then present it to the “real doctor.” Discussion and adjustment ensue as necessary.

          • anon

            You’re one of the rare NP students, then. None of the NP students that “rotate” at my institution do anything remotely close to that. They’re wallflowers — they hang around and shadow the NPs from 9-5 and go home afterward to write up some fluff article on a topic unrelated to patient care (some stupid capstone project or something). These are students who will be graduating within a few months and my state is one those that gives NPs/DNPs full independence. Scary!

          • Rachel Prewitt

            I don’t know if you’re the same anon that I just replied to below, but I will echo your sentiment that there are some scary graduates from many programs. I’ve met several of them who are MDs. My university program prides itself on educating some of the “best” graduates, and if it is true that most NP students do nothing but sit on the wall, then perhaps that is the case. Certainly different programs can interpret requirements in different ways.

          • gwen rothberg

            Our university program is tightening up as well – “the days of getting in to the program because you could get a student loan are over” the grad school coordinator announced. Wow. GRE, competitive rating, minimum of 2 years of critical care experence (full time) and at least 1 post licensure certification just to get in the program. The average age is between 38 and 44, and the candidates come to the program with an average of 12 years of licensure when they apply. Yes, its a different kind of education, but if you want to work in the clinic or primary role, do the FNP. If you want to be in an intensivist or hospitalist service, do the acute adult care track. I don’t have a desire to give sports physicals and z-packs at Walgreens, but rather to stay in my ER, and I’m sure my program will prepare me more than adequately for that.

          • kjindal

            except graduating MDs are still not licensed to do anything independently until residency, a period of intense, mostly independent inpatient management of SICK people. I can’t imagine the many NPs (and worse, NP students) where I work doing independent inpatient management. that is scary, indeed.

          • Suzi Q 38

            My two M.D. specialists made huge mistakes with my care.
            It happens….I realize that I have to be careful with all medical professionals that treat me.

          • Guest

            Imagine how many mistakes would be made had you had NPs or PAs working on you instead?

          • Suzi Q 38

            That is a consideration, but who knows if errors would have been made or not?
            I was not in the hospital at the time, so it is different.
            The neuro did not want to follow the suggestion for more tests by the PT. The PT knew that I needed more tests, but he didn’t push it because he didn’t want to “ruffle the feathers” of the neurologist.
            If the neurologist was an NP, h/she might have been more open to listening to what I had to say, and gone to talk with the PT like I had asked him/her to. I asked for more tests, based on what the PT was concerned about (a spinal condition). It turned out to be spinal stenosis with ossification and signal changes that caused some paralysis in my legs. The progression was very slow for about a year, but there just the same.
            Since this is only a hypothetical situation, an NP may have talked it over with the PT and ordered a full MRI and nerve tests on both legs. That is what the PT had suggested.
            Had the doctor agreed, my spinal stenosis would have been discovered a year earlier. My paralysis would not have progressed due to the prolonged duration of signal changes on my spinal cord.

            In reality, I would not be seeing an NP or PA for my neuro problems. On the other hand, in my case, the NP’s and PA’s that were around were more helpful and at least listened, without treating me as if I were a hypochondriac.

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

            Why do you assume that?

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

            Wow Anon. I’m an MD but I was an NP first and that characterization of nursing students is insulting and condescending

          • D. Gail Wong

            Please don’t forget that resident work hours have severely restricted what they can do on the floors as well. Most NP students have been RNs for quite a bit of time and have been around patient care in a more than “wallflower” capacity. I believe many of the acute care programs require a minimum amount of RN practice in a hospital setting prior to entry.

            BTW there is no such thing as full independence, even for a physician. We all practice under practice guidelines and protocols.

    • Theresa Bubenzer

      I think the real issue is not morality of NPs or MDs, who would sacrifice patients to profits at the behest of hospital employers. The issue is not with qualifications to practice in hospital settings. The real issue is economic. It is way more expensive to go to medical school and the training required to get an MD. It has more prestige. But, studies have shown that the results of treatment by NP and MD are comparable. California is a collaborative practice state. Any NP working has to satisfy practice requirements for working in a hospital, which would require adequate training and a collaborative physician who has to sign off on the NP’s practice. There are no NPs running amok in the hospital corridors, undermining the economic interest of any MDs. That’s very unlikely to occur. As to the people who say snarky things about nurses running hospitals–I have to wonder at your naivete. It has been my experience that quite a lot of the administration in hospitals is made up by nurses.

  • Homeless

    Midlevels are already working in hospitals. My spouse was in the hospital for 12 hours before he spoke to an MD.

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

    We need the name of this community hospital so we can broadcast to the public that you will only see a lowly nurse when you enter there for treatment.

    I’d love to see this hospital’s marketing slogan: “our hospital is so crappy a nurse can run it!” LOL

    • W.B.

      With America’s disdain for the poor and disenfranchised, it will probably be them who are stuck in “nurse-only” hospitals, they will be told not to complain, after all “Beggars Can’t Be Choosers!”, the 1% will still get First Class Treatment by Real Doctors, you betcha!

      • Guest

        In every area of this country the wealthy receive a better standard than those who cannot afford it…except in health care. It is about time that money should buy better health care.

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

      That is a terrible and insulting thing to say.

  • michaelhalasy

    I’ve been a PA for many years, and have practiced in both hospital and outpatient settings. During my training I not only had to rotate in surgery, but in the hospital as well. I currently practice and do research at one of the most premier medical centers in the world. We have several hospital services that are primarily managed by PA/NP providers including a hospital medicine and cardiology service. There is a consultant available if needed, but the PA/NP manages the patient during their hospitalization and subsequently dismisses them. I now practice in a complex non operative spine practice, and I have my own panel of patients and function independently. I have physician colleagues I can use as a resource as needed, but they are generally not involved with my patients unless I need them to be. The point is, this is done elsewhere, and it works.

    Mike

    • W.B.

      You are a Physician’s Assistant yet you are not actually an Assistant to a Physician but basically act as a Physician yourself? Do your hospital patients know that they are not being treated by a real doctor, but by a nurse or an assistant?

      If Nurses and Assistants can act as Doctors, then why do we even need doctors? On the other hand, maybe next there will be another new role, an Assistant’s Assistant, with maybe just a Community College degree, and it will be deemed that they are capable of acting as a full-fledged Assistant, and down we will go…….

      When I am flying from Boston to LA I want to know that both a Pilot and a Co-Pilot are up there in the cockpit, I don’t want the airline to save money by putting up two Co-Pilots or a Co-Pilot and a Flight Attendant :-/

      • michaelhalasy

        If you are arguing that our title is inaccurate, then I completely and wholeheartedly agree with you. I don’t “assist” anyone. I haven’t for many years. The AAMC and the AMA for years limited entry to the medical profession to inflate salaries. Now there are workforce shortages that they created, and they bemoan the entry of other professionals. Disruptive innovation occurs because there is a void, and this is what is occuring with PA/NP utilization. As far as practice goes, there is already talk in the education circles about shortening medical schools to 3 years in length. PA school is already 2.25 years. The differences aren’t that great educationally, although there are some. The big difference is in residency education. This is where physicians become physicians. If you are arguing that a new graduate PA cannot practice to the level of a first year post residency attending I would completely and utterly agree. But years and years of experience temper that difference. In our practice, it is interactive and collaborative. The physicians ask other physicians at times questions about their patients, I ask them questions at times…and (GASP) they occasionally ask me for my thoughts about their patients. Why? Because I also practiced in other specialties over my career and in some circumstances, may know more than one of them about a particular condition. This doesn’t happen often, and to be truthful, I consult them more often then they do I, but it goes both ways. Because the physicians I work with are more concerned with good care then protecting egos. I’m also heavily involved in research, serve as faculty to teach physicians research methods, have a research doctorate, and also serve in leadership positions. We need to change the hierarchical model to a circular model of team work. Much of the time, the physician should be in charge, but not always. Perhaps it is a wound issue that the nurse may know more than the physician about. Than the nurse should lead the team. Perhaps it is a patient with a condition that an experienced NP has seen before, perhaps they should lead the team. We need to all be able to keep our egos and titles in check….and wait for it. Take care of patients in the highest quality manner possible. Just my 0.02 cents.

        • Close Call

          “If you are arguing that a new graduate PA cannot practice to the level of a first year post residency attending I would completely and utterly agree.”

          A very common sense statement. There’s a big difference between an NP/PA working for 20 years in the military independently and a new grad. But that’s exactly the stated goal for the AANP: to practice independently and with the same level of responsibilities as a first year post residency attending.

          That’s where the sideways glances from physicians come from… “like, really? I don’t even trust an intern taking care of patients without supervision… you’re going to let somebody fresh out of NP school do it?”

        • michaelhalasy

          Oh, and by the way, my patients always know that they are seeing a PA. We are a referral practice, and every internal physician referring patients to me has to click a box that the patient is okay to see a PA/NP. For outside referrals, they are told that they will be seeing a PA if they are scheduled with me, if they wish to see a physician (and some do), they can be scheduled with one of my colleagues. There is no deception present. Everyone is aware up front. It’s the only way to ethically do this.

        • Dana

          “If you are arguing that our title is inaccurate, then I completely and wholeheartedly agree with you. I don’t “assist” anyone. I haven’t for many years.”

          Well if you would like to drop the “Assistant” part of your title and become a full-fledged Physician, I understand there’s a process for that.

      • Dave Mittman, PA, DFAAPA

        Sorry to say but you are picking on our poor name. If you are a physician who has worked with PAs you know we don’t assist.
        I hope you don’t need to see one of us as you will be quite angry as we do exactly what physicians do. Will you work with us to change this foolish name?
        Dave
        Dave

        • anon

          I work everyday with PAs (and NPs). While I appreciate the work they do, no, you don’t do “exactly what physicians do.” For any given patient presentation, my differential is going be longer and stronger than a midlevel’s. I will be ruling in and ruling out far more things than you probably are simply because that’s what 7 years of rigorous medical was designed to do — make me into a differential diagnosis machine.

          Even with something as fundamental as differential diagnosis, you don’t do the same job as I do. So please, stop saying that you can. You have a good job, you’re good at what you do. But you don’t do what I do and it’s incredibly annoying and rude to hear someone with a fraction of the training I’ve received say they’re equivalent to me. At the very least, it’s incredibly arrogant.

          • LastoftheZucchiniFlowers

            You obviously do NOT work with PAs and/or NPs or if you do – your hubris as a ddx ‘machine’ is misplaced. ‘Incredibly annoying and rude?’ Wow. Time for a new job, anon.

          • Dave Mittman, PA, DFAAPA

            Anon: please. You have no idea how good I am. In primary care, I am really good.
            I have no idea how good you are.
            What I do know is you are not open to considering new possibilities which makes me a bit better than you. Open your eyes a bit.
            Dave

      • LastoftheZucchiniFlowers

        Your ‘co-pilot’ IS often a ‘pilot’. He or she is fully qualified and is often moved freely from left to right seat. This is especially true on international flights. The FAA is quite clear on this. Nonetheless we have all read the disgraceful stories about pilots reporting to work drunk, stoned and worse. The facts are simply that the ‘credential’ does not always translate to better (or worse) outcomes.

      • Suzi Q 38

        There was a tie when pharmaceutical reps had science degrees or were nurses. Then that requirement or preference relaxed, and all you needed was a degree in anything.

        Soon the requirement will be a HS diploma, because they want the reps to be “delivery people,” and pay them $15.00 an hour, without benefits.

        My point is that to save money, they will use NP’s. It remains to be seen what will happen to patient care.

        My neurologist was terrible. He is not the only neurologist “in town,” so I am moving on to a better one.

        A good neurologist would not be equal to an NP.
        14 years+ practice would not equal the study curriculum of the NP.

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

      Thank you. Let’s work together, not make derogatory or insulting remarks about each other.

  • disqus_qJEMXTKtR1

    Isn’t there a greater point to this article other than physicians vs. NPs/PAs? Qualifying and credentialing the level of care for NPs/PAs to work in an acute hospital setting will eventually be figured out.

    “Asserting control over the committee” by the hospital administration is a threat to all healthcare professionals as managing inpatients will be at the financial behest of profit-seeking business people gaming the system, and not by well-trained doctors and nurses. Across our country this happens more and more each day, while physicians and NPs/PAs have not gained leadership over this problem. The answer “It’s just going to happen” does not compute when it comes to patient care.

    We must focus on this question: How far do we allow medical decision-making be made by business entities (eg. insurance companies, hospital administrators, and governmental agencies, etc.) in taking care of our patients?

    Gene Uzawa Dorio, M.D.

    • LastoftheZucchiniFlowers

      Gene – you know that ‘controlling committees’ has been a mainstay of inpatient care for DECADES. The power and turf battles which undermined care 25 years ago are now worse than ever. I can recall wasted hours in physician-led committees when otherwise erudite men and women battled over inane issues such as ‘who will be in control of the hospital at what time of the day’. Crazy? Yes. This is what has let so many non-surgeon physicians AWAY from inpatient care. PS – ever notice how those of us in medicine like to define other professions by what they are NOT? In my field I frequently hear the term, “non-dermatologist physician”, leveled at my non-specialist (MD!) colleagues. It’s a dig – like it or not. Do we call a woman a ‘non-man’ or a child a ‘non-adult’? We had all better wake up.

    • Theresa Bubenzer

      That’s a lost cause. The insurance companies control much of what is given in medical treatment and medication by controlling what is reimbursable. You have to be out of the loop not to realize that salient fact. The government has a large say in what is reimbursed by Medicare, Medicaid, etc.
      You are beating a dead horse. Medical decision making is being made in legislatures by really untrained laymen. (Transvaginal ultrasound in Virginia ring a bell?)

  • Kathleen P. Kettles

    Every time there is an article about NP/PA’s, the comments by physicians are both factually inaccurate and disrespectful. As a nurse attorney for the past 26 years and a medical malpractice attorney, I can assure you that there are many physicians who don’t or can’t properly formulate differential diagnoses and provide substandard care regardless of their “superior” education and residency programs. So, instead of demeaning others perhaps the time would be better suited to identifying the level of training necessary to perform competently in the acute care setting. I think there is a legitimate concern about permitting NP’s without significant acute care nursing experience or an NP acute care residency practicing independently in a hospital setting. I think the Acute Care NP and PA is a good start. However, and I don’t know the answer, I’m assuming that most hospitals have their own criteria for hiring, and I don’t know if that includes criteria for either the experience or acute care certification. Would love to hear from the NP/PA’s about this.

    • Guest-NP

      That’s actually a multifaceted issue. National guideline ( not yet reinforced) state that to practice in acute care settings, a NP must have an Acute Care training and board certification ( ACNP). However, as the article above demonstrate, many do not even know about the fact that all NPs are not FNPs ( Family Nurse Practitioners) , hence, many hospitals have hired FNPs for inpatient acute care settings. Once the scopes/roles have been national enforced, it will no longer be possible to have FNPs in acute care settings, the same way that ACNPs cannot practice in primary care. They can, however, practice in outpatient settings, as long as it is an acute care/specialty clinic.
      I am always surprised to read the level of animosity many physicians demonstrate toward NPs and PAs- and yet, the group I work with seem very happy to have 12 hours night coverage for their ICU patients, giving them a change to actually get some sleep despite being “on call

  • disqus_qJEMXTKtR1

    Patient care is provided at many levels in a hospital setting. Some of it is dictated on the outside by Medicare, private and HMO insurances, but within each hospital comes policies and procedures initiated through a balance amongst Medical Staff, Administration, and Board of Directors. When this balance is skewed (as it has been at our California hospital) then new directives and rules promote profit and sacrifices patient care. Bringing in lower paid midlevel providers subsequently enhances profits and augments Administrative salaries, bonuses, and golden parachute retirement packages. (Our small community hospital CEO yearly compensation totals over $700,000.)

    Most physicians in private practice these days are only trying to financially survive, so they ignore hospital “politics.” When business Administrators scurrilously influenced our Board of Directors then used their votes to assail the Medical Staff, chaos developed. Physicians, especially those on the Medical Executive Committee, have been threatened or eliminated through “Corrective Action” and “Code of Conducts” while whistleblowing on behalf of patients and their right to quality care. Apparently, this is templated strategy executed by hospital Administrators throughout the country.

    The NP/PA issue is only the tip of the iceberg for medical professionals struggling to maintain decision-making for our patients. Let us not bicker over the amount of time, effort, and experience we bring to the table. A rational approach will evolve. Keep in mind the bigger picture, for if we do, in the long run we will all be better off.

    Gene Uzawa Dorio, M.D.

  • mridoc

    In my experience as a physician working in the VA, I found PA’s and especially NP’s to over-order expensive radiology studies compared to family practitioners. I suspect that the savings that is expected from using non-physicians because of their lower salary will be nonexistent and possible more expensive if one considers the cost of over ordering studies.

  • Patricia

    Interestingly NPs take enormous caseloads, and given the complex clients, cover when the psychiatrist goes to Europe. Social workers, clinical psychologists, medical students…even chaplains are invited to APA. This is the conference that will introduce DSM-V, our shared source of guidelines for the clients we share, and cover when the psychiatrist load is excessive. I had to enter through the back door on request on a nonadvertised loophole called advocate (lower than chaplain), even though I have the same liability and caseload of my colleagues that are psychiatrists. I did not get extended residencies in training, get paid about twenty percent of a medical salary. I follow evidenced based practice and bound by DSM guidelines. Why does the medical professionals not incorporate our profession for the areas we are strong in. We are trained intergratively, but are hired to prescribe,,,as quick as possible. I sense a callousness in the response from trinue 6 days ago. NPs are not the source of a problem, and have comparably good outcomes in treating despite professional barriers and lack of support from more extensively trained professionals. Invite to trainings and conferences that respect our intelligence, compassion and experience.

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

    Arghhhh! Why is this conversation always so ugly and divisive??? Let’s work together. Doctors have to get off their resentful high horse about how bitterly they suffered and for how many years so they can know everything, and nurses need to stop pushing practice independence as a final solution. We can help each other.