Independent nurse practitioners are not the primary care solution

In her post, “The only thing that truly separates doctors from nurses,” Dr. Leng is right that our current system creates a great deal of confusion for patients. Clothing, titles and even the word “Doctor” are no longer clear enough for people to understand which member of the health care team is caring for them. However, her suggestion that ultimate responsibility for the patient is the only distinguishing feature is incorrect. The deeper differences must be recognized as state legislators consider granting independent practice to nurses, as 18 states have done already.  We have to think carefully about the implications of such changes for patients and the American health care system.

Saving money should not be the main factor for decisions that impact patient care and safety. Cutting costs by substituting nurses for physicians would lead the United States to two classes of care — one run by physicians and a second by differently qualified health care professionals. Some of our most needy citizens, such as those with little or no health care coverage, are most likely to lose their physician and be given a nurse. Every American deserves to have a personal physician and a nurse!

Contrary to Dr. Leng’s comment, the most important distinguishing aspects between physicians and nurses are indeed knowledge, skill and ability. Experienced non-physician providers are invaluable, but they can’t validate a variable educational process. Nurses are not physicians: nurse practitioners complete 5,350 hours of education and clinical training during five to seven years, varying from state to state, compared to primary care physicians 21,700 hours of education and clinical training during 11 years, that is standardized and consistent regardless of state or school. The additional training physicians receive brings extra breadth and depth to the diagnosis and treatment of all health problems, acute and chronic, as well as injuries, mental illness, health and prevention. A primary care physician is trained extensively to make the right diagnosis, even when symptoms are not clear. By contrast, nurse practitioner training focuses on ongoing treatment after diagnosis.

Yes, there is a primary care shortage that is expected to grow as the population ages and more Americans gain insurance coverage under the Affordable Care Act. But the answer cannot be to substitute care. We believe the answer is more physicians and more nurses working together in integrated, coordinated, physician-led health care teams through the patient-centered medical home. This model has proven to increase the quality of care for patients and improve cost-effectiveness for the health care system. Independent practice of nurse practitioners has not solved the primary care access issues or improved health outcomes at lower costs in those states that now have it. It is not the solution.

We value nurse practitioners. Family physicians work with nurse practitioners across the country. They are critical players on the health care team — but they are not physicians. A physician-led patient-centered medical home ensures we have the health care professionals we need and that every patient gets the right care from the right medical professional at the right time.

Reid Blackwelder is president-elect, American Academy of Family Physicians.

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  • Chris

    Nurse to drag out dodgy “study” which “proves” that “nurses are just as competent as doctors” and that “there’s no difference in patient outcome whether a patient sees a real doctor or just a nurse” in 3…. 2…. 1….

    • ProudOkie

      yawn……next patient please

      • Matched M4

        Jesus, you’re retarded! I feel so very sorry for your patients. Ugh.

      • 3rd year med student

        And, with one response, we know that you have absolutely no idea how to critically evaluate literature! Scary.

        I expect the M1s I tutor to be able to interpret scientific papers. Did they not teach you that in “pretend doctor” school? Or was that material just too difficult for you? Either way, it’s nice to see the low standards NP schools have. Guess all you need is money to pay tuition and you’re in!

    • Mengles

      With the actual research being sponsored by nurses with shoddy, non-quantitative outcomes.

    • Suzi Q 38

      You can find studies that have the outcome that you or any drug company wants.

  • southerndoc1

    For the past decade, the AAFP has been pushing the bullshit line that you receive medical care not from a doctor but from a team. Well, time to reap what you sowed, Dr. Blackwelder

    • ProudOkie

      As always – right on the money. And do you think after all the hell NPs have caught from the AAFP (not frontline physicians) concerning being second class providers and listening to this two-tiered medical system crap that we will ever want to work on a team with someone who thinks so little of us? As I have said in the past, if I ever have to close up my private practice, I will work for a corporation that has a “physician-led team.” Everything will be complex, I will realize I know nothing, secondary hypertension, vasculitis, glucose over 250, right-sided heart failure, chronic ear infections…..whatever – name it; everything but what physicians have named as within our scope (ear infection, green nasal snot, scabies) will be shoved upline and I will go home at closing time and collect my $120,000 and all my benefits. Have fun “leading.”

      • southerndoc1

        ‘Have fun “leading.”‘
        Leading: signing off on team-generated care plans, organizing in-house training on change management and interprofessional learning, and typing up agendas for the morning huddles. Don’t forget to empty the trash on your way out. Well done, AAFP!

        • buzzkillerjsmith

          Change management is required for leveraging synergies and pre-concepting win-win situations. You might not like that, but it is what it is.

          • southerndoc1

            Sounds like a paradigm shift to me.

        • ProudOkie

          I believe more in serendipitous decentralization with experimental meritocratization (new word for a new age team leader)…..

      • buzzkillerjsmith

        Go home at closing time and make 120k. I’d like me some of that. How hard is it for a doc to get into PA school?

        • ProudOkie

          Right? That’s where it is with experienced NPs. Don’t know about PAs. I could get even more with all of my experience – but on the big ol’ team I would only be treating poison ivy and eye infection (if no photophobia, photophobia goes to the team leader) and stuff between toes. Better for me! Low stress stuff and pass the buck to my leader!! Wait a minute….I’m starting to like this concept!

          • buzzkillerjsmith

            Hell, I like it too. I’m reading up on poison ivy right now.

        • ProudOkie

          Dr Buzz, will you please be my team leader?

          • southerndoc1

            LOL

          • buzzkillerjsmith

            I’m trying to get traded to the derm team but no one will take me. They prefer a “med student to be named later.”

      • ProudOkie

        Geez – all the thumbs down….can’t even make y’all happy when I agree with you!!

    • buzzkillerjsmith

      Do you think it’s corruption, stupidity, or both?

      • southerndoc1

        I’ve asked myself that many times, and I choose the more charitable response: no one can be THAT stupid.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          IMO: Fear and need for external validation…

          • southerndoc1

            “external validation”
            photo ops?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            insecurity

      • ProudOkie

        The hammer the AAFP dropped on NPs was so egregious that I even remember the date – September 19th, 2012. I have that article readily available. Any student I encounter – I show it to them. I let them know that no matter what anyone says or does, the AAFP thinks we are second class providers – never forget it. It is in writing – we are the second tier in a two-tiered system and every patient deserves one of them but they don’t deserve one of us. Any patient that asks about the differences, I readily let them know that physician groups (not individual physicians) think they are receiving second class care and show them the article. I tell them about the difference in hourly training between the both of us and tell them they must make the choice. That article is a badge of honor for me – it is a motivator. And now, the new AAFP mouthpiece is doing it again. I love it. I use these articles – they keep driving the wedge and the chasm grows deeper. One of my rallying cries is why would an NP work on a team that thinks they provide second class care? Or where an individual believes we are only valuable WITH them? My answer for my NP colleagues if they work on a “physician led team” is to let the physician lead. Do no more than what is naturally expected of you. Ask about which class of anti-hypertensive to use, ask questions – lots and lots of them. Refer up the food chain, always and often. After all “you really don’t know what you don’t know”. But your team leader does. And after all, the buck stops with them – and that is what they want, cry for, beg for. And they deserve it too……

        • southerndoc1

          The AAFP is fighting a non-existent battle that they’ve already lost. That takes some sort of talent, I guess.

        • Matched M4

          I will tell you explicitly what many/most (?) of us in medicine think of of NPs: You ARE a second-class care provider ProudOkie. Medical students who haven’t even started residencies yet provide better care than 99% of NPs/DNPs. Easily. Why? Because, by the end of 3rd year, we already have far, far more training than you will ever receive in your life. Your whole NP education is a joke — if underwent that training as a med student, I could easy go through ALL of NP/DNP training in a semester or less. LOL!

          Hell, as a 4th year med student, I’ve had to save “experienced” NPs butts on more occasions than I can count. These are graduates from prestigious schools, like Columbia, Duke, etc. The NPs come to us M3s and M4s for advice in forming their differentials before presenting to the attending. That’s just pathetic. We’ve had NPs diagnose TIAs as migraines. MULTIPLE times! Jesus. Good thing we had an M2 shadowing that one time when he noticed the NP getting ready to discharge a patient with a TIA and made the residents/attendings aware of what’s going on. I’ve seen NPs who don’t even know the differences between Gram-positive and Gram-negative bugs and they don’t understand why it’s important to know the difference.

          Basically, the caliber of a nursing midlevel (as a student and as a practitioner) is very, very low. So, I hope that clarifies for you, ProudOkie, what many of us in the medical profession think of your joke of a profession. Am I worried that a midlevel would ever replace myself or anyone that’s been through *real* medical training? LOL no! We just laugh at your guys’ mistakes and lack of knowledge, is all.

          • ProudOkie

            You speak as you are expected to speak. Nothing new here. Move along.

            And who mentioned anything about replacing your profession? Not me.

          • ProudOkie

            LOL. LMAO. Same person same story different screen name.

  • Dave

    If the goal is to create political will against independent NPs, I’m not sure if this argument is very effective. Has the AAFP ever considered reframing the debate not as MD vs NP, but MD vs faceless billion-dollar hospital corporations who only want independent NPs so they take your doctor away and only let you see a nurse so their CEO can get a bigger bonus?

    This approach is much more inflammatory, but might be more effective. Sweet Nurse vs Greedy Doc is a debate we stand to lose, but Noble Doc vs CorpMed CEO is a winner even before everyone trots out their numbers.

    • southerndoc1

      “Has the AAFP ever considered reframing the debate not as MD vs NP, but MD vs faceless billion-dollar hospital corporations?”

      That would be a strong pro-patient, pro-doctor position, so it will NEVER happen. The AAFP spent the first part of this century whoring themselves out to the EMR industry; having done their damage there, they’re now working overtime to do the bidding of their corporate masters: i.e., tototally remove solo, small and private practices from the path of the BigCorpMed juggernaut.

      • Dave

        Well the terms of the debate need to be changed or it’s already lost. I think the lay public misunderstands this debate and thinks it’s just greedy docs who don’t want to compete with NPs, but if we still lived in a world of small and solo practices, I think most MDs would be more than willing to compete with them. Frankly, robust competition under those circumstances would be good for both professions. But that’s not the world we live in.

        No, this debate has to shift to doctors vs. faceless corporate minions who only care about the bottom line and are spending millions on lobbying so they can take away your doctors and only let you see nurses.

        It needs to be Doctors vs. Greedy Insurance Companies who want to force you to see a nurse while raising your premiums so they can pay their executives bigger bonuses.

        This is the kind of rhetoric that seems to work in healthcare debates; the first person to say “number of hours of training” has already lost. The NP is not the MD’s enemy, and every time we attack them it only makes us look worse because in truth they are competent, caring professionals who have also dedicated their lives to taking care of people.

        The enemy is a hospital association CEO in a $10,000 suit flying on his G450 talking to another senator about independent NPs so he can cut his payroll in half without losing revenue. He must find it amusing to watch us little people attacking each other.

    • buzzkillerjsmith

      Well said. Divide and conquer is Corpmed’s approach and the rummies at the AAFP have either fallen for it, have been corrupted, or both.

      Unfortunately, however, right does not always make might. If I had to bet, I’d bet on Corpmed. Medical students would be wise to think twice about going into primary care.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      @azmd, if you are reading, this is the message that needs to be taken to the public, and if AAFP won’t do it, then you guys should do it yourselves….

  • ninguem

    Independent nurse practice is going to happen…..well, it is happening, the whole Left Coast of the USA…….and apparently Oklahoma.

    But it’s not going to “solve” anything. There are lots of “do it all” NP’s, but most gravitate to a “specialty” in a way, so you get the women’s health NP, the pediatric NP, mental health NP, etc.

    In reality, in the market, a FP will be worth some multiple of NP economically. If that FP has to be replaced by a pediatric NP for the kids, a geriatric NP for the nursing homes, a women’s health NP for PAP’s etc., the FP will be worth some multiple of what the market pays NP’s.

    If you snapped your fingers and suddenly the entire country were populated by independent NP’s, healthcare would cost exactly what it costs now, and may well even be more expensive.

    I don’t see any of the countries often held as our “betters” in healthcare…..Canada, UK, France, Germany, the usual…….I don’t see any of them adopting a PA/NP/midlevel model.

    • ProudOkie

      Hi ninguem,
      In Oklahoma, NPs are independent concerning everything but writing prescriptions. The Board of Nursing requires a physician to sign a form stating they will supervise the APN concerning prescriptive authority. I wanted to clarify that. NPs ARE allowed to own their own practice without physician involvement in our state. There are many private NP clinics in Oklahoma – I can count 10 without even thinking in the RURAL areas surrounding Oklahoma City. I only know of ONE NP clinic in the metropolitan “non-rural” area of the city. Where I practice, in a remote area, there is no one. There are also more and more in small towns all across the state. I know of 5 that have opened in the last year. Just some info and data for you.

      • ninguem

        Yeah, I know they can practice independently. Same as my state. We don’t have anywhere near that number of independent clinics.

        Though there are lots of clinics that are hospital-owned, and virtually 100% NP-populated, though they keep a doc on the string to “supervise”, a term I’ll use loosely. You know the drill.

        On a daily basis, I have trouble tracking down “Doctor” Mary Smith, the “cardiologist” on a new patient in my practice, trying to find old records. I can’t find “Doctor” Mary Smith, because she’s a NP at a primary care clinic run by Big Box Hospital.

        ……oh and charging facility fees, so that NP primary care visit might rake in $300 for that Big Box.

        Two issues. One, the misrepresentation of credentials.

        I’m not accusing you of that, you know that of course.

        But I see it every day.

        Second, and more to the point of the thread, the cost of healthcare is not changed in any way, the Big Box uses facility fees to double the cost of a healthcare visit.

        So bring on the NP’s for any number of reasons, but I for one don’t expect it to change American healthcare in any significant way.

        • DISQ_user9801

          “On a daily basis, I have trouble tracking down “Doctor” Mary Smith, the “cardiologist” on a new patient in my practice, trying to find old records. I can’t find “Doctor” Mary Smith, because she’s a NP at a primary care clinic run by Big Box Hospital.”

          ^^ this happens! ^^

          • Suzi Q 38

            Stuff happens.

        • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

          Insurance companies reimburse me less than Medicare for my patient’s visits.

      • ninguem

        So, not exactly independently. You own your own practice as a business entity, that’s fine.

        Somewhere in the system, there’s a physician who is responsible for your prescriptions. I assume there’s some sort of compensation somewhere along the line for the supervisory responsibility.

        We’re counting differently. We have lots of those in our area too. They exist as part of Big Box Hospital Group, they charge facilities fees, their fees are far more than my private clinic.

        And the hospitals staff them with nurse practitioners……usually because no doctor will work with them, and for good reason. Yes, somewhere in the system there’s a well-paid physician signing off those prescriptions and doing some “supervisory” work.

        And the hospitals have been known to held out the nurse-practitioners as physicians. I called the medical board on my own hospital, they open such clinics to compete with my private office, then claim in the media that the NP, who has an interest in arthritis, is a “rheumatologist”. That crosses the line on the Medical Practice Act.

        They really shouldn’t leave a paper trail in the newspapers like that.

        I mean it’s just a warning and a retraction in the newspapers, but still……..

        I for one am counting the NP clinics that are 100% completely independent, no physician at all.

        That’s allowed in my state, I gather not yours.

        I know of a few, but not that many.

        • ninguem

          Oh, another reason why you’re seeing more NP’s in the rural clinics. If you’re running a rural critical access facility, you HAVE to have a Nurse Practitioner on staff.

          I couldn’t believe the regulation, but there it was, and I confirmed it with our State’s Office of Rural Health. It’s Federal Regulation.

          So, there I was in a rural area that geographically qualifies for the rural critical access designation, 80 miles to the nearest city with a hospital over 50 beds. No general surgeon in the county. The usual low pay for rural practice.

          Hey, maybe I can tweak some parts of my practice and qualify for the Critical Access designation. It would allow me to see more Medicaid without going bankrupt. Better service to the community, as the Medicaid patients would be more likely to have a doctor. I mean besides the NP that our hospital called a rheumatologist in the newspaper.

          So, I read through the regulations, and there it was. If I saw all my patients, no critical access designation.

          If I hired a Nurse Practitioner at least half-time, then I could qualify.

          CMS feels the quality of my practice is improved if I hire a NP.

          I like to call it the Nurse Practitioner Full Employment Act.

          Instead, I left the rural area.

          • ProudOkie

            The NP requirement is unbelievable! I do not agree with that at all. If you are a licensed provider and are within your scope, you should not have to depend on another provider to open a clinic. Respectfully, that is how it feels as an NP trying to open a clinic in a rural area and trying to hunt down a physician. That whole set up is ridiculous. I did not take any federal money. All on my own dime. I prefer it that way. Now this will set lots of folks on fire but just try to understand my side: If the AAFP wants to regulate NPS, then physicians (as a group, don’t take individual offense) should be required to supervise an NP. They cannot be required to do so then refuse to do so. This would obviously run us out of business. I know that doesn’t sit well but just think it through. I have often suggested at our board meetings that we embrace physicians not “supervising us.” In the end it would turn into a restraint of trade issue and help us gain more independence in the long run. We have to have them to practice but they will not make themselves available to us. That wouldn’t work for long and we are needed too badly to simply fall by the wayside.

          • ninguem

            Whoever it is that’s doing this “supervision” or “collaboration” or whatever they call it.

            Is this doc doing this for free?

            Nice guy, if he is………

            I had a glaucoma patient. Out of the blue, an optometrist called. Wanted me to “collaborate” on the management. It meant he got to play doctor and I took responsibility for his prescriptions.

            I sent the patient to a real-live ophthalmologist.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Physicians don’t do this for free, I can assure you! As far as liability? According to the Texas Medical Practice Act, as long as the physician believes the NP to be competent, then they are not held liable for their mistakes. As if a physician is going to say, “I knew they were incompetent the day I hired them!”

            We have a bill in the legislature and if it becomes law, then physicians can “supervise” up to 7 full time NPs! They can supervise an UNLIMITED number of NPs who are treating medically underserved populations. What does that tell you?

        • ProudOkie

          Yes – exactly. There are no SPECIFIC requirements for any supervision “steps” in Oklahoma. We do it because I am obsessive about compliance. But even the sign offs (5-10 charts of 6-700 patient visits) are really worthless. Therein lies one of the NP complaints. Post visit reviews of a minute amount of charts – useless. Even in the most stringent of states, the reviews are minimal but cost an NP wanting to work rural a fortune. That is just a view from this side.

      • AKK

        So ProudOkie (or any other NP that’s reading), what’s the difference between you and a primary care physician in terms of your day to day functioning? I’ve followed a few of these discussions and find myself getting confused. There’s a fairly significant disparity in terms of the education and clinical training required to practice for primary care docs relative to NPs. In all of the conversations about how to remedy primary care shortages (and in other discussions about primary care), I haven’t heard primary care docs advocate for less training for themselves despite it being to their advantage (less time in training= lower educational debt and more years of earning a salary), so I’m led to believe all of that training is essential. So compared to PCPs, do you refer to specialists at a higher rate or treat patients with less complex conditions? What is the difference? Thanks.

        • ProudOkie

          Hi AKK,
          I will answer that question. Please understand that my response will be met with an onslaught on negativity so ignore all of that. My answer would be fairly applicable to any private or rural NP practicing in a low health care provider area.
          I see all types of patients, all types of insurance. Whatever walks in the door. Babies to Geri. Complexity? I start with the basic COMPREHENSIVE history, including a detailed social history and try to compile a database of complaints, symptoms, and secondary symptoms that may not seem important. From there I develop a list of comprehensive differentials, decide which system to address first (sometimes multi-system) and start ruling out from there. Types of diseases diagnose or manage? Any and everything. Let’s say for instance, I find some type of nebulous autoimmunity – basic autoimmunue workup, dig deeper if I discover something (unlike many PCPs, I try to help the specialist out as much as I can if I think I will need one) and refer based on complexity and treatment that is outside of my scope. My referrals are LOWER than the average provider. I manage uncomplicated non-displaced fractures (that saves thousands in referral money), I close most any wound that comes in the door (if there are no contraindications – and PCPs know what those are). Again, onsite – saves thousands. I manage all of my own diabetes and hypertension. I work up for secondary when appropriate. We do well childs, DOTs, IV fluids in house, biopsies of every kind, and all of the other minor emergencies (subungual hematomas, fishhooks, blah blah). I refer the same as any other provider (MD, DO, PA, NP, CNS) would. If they have malignant or complicated hypertension, they deserve a cardio, all undiagnosed GI issues. All of my NP colleagues do this and some do much more more on the emergency side as they are EMTs and emergency RNs so they have a lot more experience. I know my limitations. If you walk in my clinic, you will immediately know there are no MDs or DOs/physicians. You must acknowledge this in paperwork. You must acknowledge you are being treated by an NP. Once in the room, my colleagues and I introduce ourselves as NPs – it is written on our badges. I make all employees wear them.
          All of this is nothing new – it is typical of any NP clinic in any part of the country except for the corporate owned ones. Differences between one of our clinics and a physician clinic? Respectfully, treating patients like customers, truly spending more time listening, working with patients without insurance, utilizing fully transparent pricing for patients without insurance. We do no testing or procedures without first letting them know the cost.
          Most importantly, we work within our scope. We stay right there and know when to pass on to a specialist. NPs practicing in a corporate setting will practice much differently than an NP working in a rural setting. If you will notice, the AAFP always puts out blurbs that have the term “Independent NP” in the title. We are not independent. We are part of broad based team – in our case, we developed the team. This is the rub with the AAFP. A physician did not develop and set up our clinic. But our costs are lower, patients are happy, the care is comprehensive, evidence based, and I never refer without absolute necessity. I always call patients who overutilize the ER and tell them they must follow up with us first if we are open (we are open 84 hours a week). I think you are getting the picture. I hope this helps. Thank you for the respectful responses.

          • ProudOkie

            AKK, one other thing that may be important to you though the physician groups greatly discount it. NPs must have a 4 year degree in nursing. A lot of us worked as nurses first. So we are immersed in patient care, medications, procedures, pathophysiology, comprehensive assessment (all of those course are required in BSN programs) and the ability to interact with and understand patients about 4 years before medical students start school. Understand – this is not meant to be offensive. Their undergrad degrees are in the sciences so we have a jump on them INITIALLY in the PRACTICE part. However, once they get into their medical training, they quickly catch up because of the sheer number of hours they are actually in a hospital or other setting – they are “culturally immersed” in a short period of time and we are culturally immersed over a 4 year period. Not saying those are equal AT ALL. Just comparing – really apples to oranges. But you need to understand that a Family Nurse Practitioner degree is more than a “two year degree.”

          • AKK

            Thanks so much for your thorough reply- I really appreciate it.

    • ProudOkie

      I understand your thinking – but it’s not right, very respectfully. NPs take care of babies to geri – I’m not sure why you think we are so specialized. I see newborns to teenagers, adults, geriatrics, do WWEs, all of those things. We are already doing all of these things and have been for years. I do understand your point that some NPs are specializing but the majority of NPs are family practice.

      • Scott

        I think he is saying that a more general NP isn’t going to have enough depth of knowledge to even start to have the diagnostic capacity of a physician. Since a specialized NP will have a greater depth of knowledge in a specific area, a team of specialized NPs would more depth of knowledge, closer to that of a physician. However, I still disagree that this would work anyways, because NPs are just trained to fill a different role than that of a physician.

      • ninguem

        I know you do.

        Most don’t.

        They add credentials calling themselves adult NP or pediatric NP, etc. They limit themselves in their own practice settings. There’s lots on NP’s in my Pacific Coast area, very few that practice full spectrum….or anything close to full-spectrum…..general medicine.

        I think they get specialized because I see them every day. They get ensconced in a certain setting. Oh, and another subtlety, when they’re in a salaried setting, they get limited hours that don’t often apply to physicians. Call, that sort of stuff, it’s on the house.

        I knew a doc, the contract was written very loosely, and he found a loophole. Absent language to the contrary, the State defaulted to a 40 hour week. The doc took call, add up the hours in the week, over 40 hours, time-and-a-half. His annual salary was assumed to be hourly, based on a 40-hour week. Take that hourly rate, time-and-a-half gets added, he made claims to the hospital. “Treat me the way you treat the nurse practitioners”.

        They tightened the contract language real quick.

        Of course some hang out a shingle and practice independently, or are in an employed setting where they do that, but most don’t.

        And heck, physicians sometimes limit their practice to the degree where they’re not much different.

        Regardless, snap your fingers and give NP’s full practice rights…….which they have already in, what, half the country more or less…….it will not do anything to affect certain fundamental problems in the system. A NP wants to hang out a shingle and go to work, they have been able to do that in my state for years. I don’t see some miraculous healthcare fix in my state. If Joe Blow MD does not want to practice in a certain undesirable area, then neither will Joe Blow NP.

        Mary Blow MD or NP is even less likely to practice in rural USA due to certain realities of gender, and the J-1 doc from India or China, even less likely to go to rural America. If undesirable to a US citizen, even more undesirable to a foreign national when they have a choice.

        NP’s will get full parity on billing, docs will perceive primary care as more the practice of nursing, more will specialize, the schools claiming to want to train primary care doctors will be perceived as glorified nursing schools.

        The marginal medical schools will close. It will not be the first time medical education has downsized (Flexner comes to mind). The marginal NP programs will close.

        The market will re-balance in some way.

        Nothing changes.

    • southerndoc1

      NPs and PAs don’t want to do primary care either. It’s a fight over who gets the hair on the bathtub drain.

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

      ProudOkie is lying to you. Oklahoma requires NPs to have a physician, they just call it “collaboration” instead of “supervision” but its the same deal.

      • ninguem

        I wouldn’t know, as I don’t live there.

        As far as I know, there is no supervisory requirement in Oregon or Washington, I live in the Pacific Northwest.

        Oregon, if you have a pulse, you can get yourself credentialed as some sort of healthcare practitioner, it can get scary sometimes.

      • querywoman

        Again, just words. It’s illegal for Texas teachers to be in a “union,” so they have an “association.”

  • Guest

    “Nurses are not physicians: nurse practitioners complete 5,350 hours of education and clinical training during five to seven years, varying from state to state, compared to primary care physicians 21,700 hours of education and clinical training during 11 years, that is standardized
    and consistent regardless of state or school. The additional training
    physicians receive brings extra breadth and depth to the diagnosis and
    treatment of all health problems, acute and chronic, as well as
    injuries, mental illness, health and prevention. A primary care
    physician is trained extensively to make the right diagnosis, even when
    symptoms are not clear. By contrast, nurse practitioner training focuses
    on ongoing treatment after diagnosis.”

    That is the crux of the matter. Nurses are every bit as important to a properly functioning medical system as doctors are, but they are NOT doctors, they are NOT as rigorously trained and tested as doctors are, and they look petty, insecure and vindictive when they try to claim otherwise. Nurses are awesome, but nurses who want to play doctor should get the quals first.

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

      “Nurses are awesome, but nurses who want to play doctor should get the quals first.”
      I agree with this statement 150%. This is also necessary for the safety of not only the patients being cared for, but the public community in general. Thank you for sharing this.

      • ProudOkie

        Again Kristy, that is opinion and not fact. Remember those pesky little 18 states where NPs practice independently? Public safety is a worn out mantra without any facts. I feel like this is the 5000th time I have typed this. Where are all the bodies and maiming and general NP mayhem in those states? And in states like mine where we diagnose and treat independently aside from prescriptions? YOU might think it is necessary but that is an opinion. As I always say – YOU should avoid those NP clinics like the plague. My patients wouldn’t leave if a physician did home visits on them. They are happy and safe and our outcomes are superb. We are one of the highest rated Medicaid providers for most outcome measurements in the entire state – that includes ALL practices. I am offended by your opinionated posit that I am a danger to public safety. This gets old.

        • Mengles

          Psst…your insecurity is showing.

          • ProudOkie

            Pssst……thanks for validating my comment. And thanks for the advice. I know you mean it well.

          • Mengles

            Sorry but when you have to say, “I feel like this is the 5000th time I have typed this,” then yes, your insecurity is showing. Sorry, but just bc you say something over and over again, doesn’t make it true.

          • ProudOkie

            Right. Got it. So. About the body maiming and the public safety issue?

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

            DNPs from Columbia University, the best DNP program in the country supposedly, took a mock version of the USMLE Step 3 test that all physicians have to take. Physicians have a pass rate of 97%

            You want to take a guess on how well the DNPs did? These fake nurse-doctors had an 80% FAIL rate.

            I figure if the “best” DNPs from an “elite” ivy league university cant pass this test, then nurses have no business pretending to be doctors.

          • ninguem

            Do you have a link for that? I’m not disputing that, I just want to see the source.

          • Mike

            They took a shortened, watered down, differently scored version:

            “According to the NBME, the DNP certification exam draws on portions of the USMLE Step 3 that test skills and knowledge related to patient management. It does not include assessments of fundamental science, clinical diagnosis or clinical skills included in the other two portions of the physician test.

            “Dr. Epperly said the DNP test uses defunct USMLE questions — not current ones — and applies a different performance standard, one set by a CACC-appointed committee.”

            And 50% failed.

          • Suzi Q 38

            I have asked for this link twice, maybe you can try to ask Jason again.

          • Suzi Q 38

            They are not pretending to be doctors. They are merely taking over a few of your duties. I would like more time with my doctors, and a call back or email occasionally when necessary.
            When an NP works with the doctor, I get more care. Don’t worry, I still gravitate back to the MD eventually if I think I need more help.

          • 3rd year med student

            Actually, they are ABSOLUTELY pretending to be doctors. Read what Mary Mundinger, the leader of the NP/DNP movement says — she spouts bullshit like they’re “equivalent” or “superior” to board-certified physicians.

            I only wish I could’ve been there to see the look on her face when she found out that her “superior” DNPs had a 50% fail rate (absolutely laughable) on a watered-down version of the EASIEST Step exam that interns don’t even study for!! LOL!

          • Suzi Q 38

            That still would not stop me from seeing an NP.
            I have a little education, so I know that they aren’t physicians.
            I am fine with “their place.”
            My friend is an NP, working in a neonatal department of a local hospital. She has worked there for about 30 years. She is going to transition
            to a large pediatric clinic and treat babies there.
            I would let her see my baby if I had one. I don’t as mine are 27 and 28, respectively.
            I figure that if she can keep babies alive in the neonatal unit, she can treat my baby for common medical illnesses.

          • Suzi Q 38

            I would like to see the source, too.
            Please post the link.

          • Suzi Q 38

            Still waiting for the link…..Thank you!

        • Guest

          Good heavens, do you constantly need validation by physicians that you ARE good enough, smart enough, and gosh darn it, people like you?

          • ProudOkie

            Actually Noni…..no. I enjoy kevinmd and enjoy all of the articles at this site. If you read this site any length of time, you will see I get ZERO validation for anything. When articles are posted concerning NPs and our profession and I disagree with them. I stand up for my profession. I could not care less if I am validated by anyone. If posters can denigrate my profession, call us criminals, and post all of the rest of the nonsense that they do, then I can post defending my profession. I understand I’m not welcome – and frankly don’t care. If Kevin Pho wants me off this site, he will let me know or block me. Hasn’t happened yet. The physician posters should appreciate an open and honest view from an NP. I am sure a lot of my posts have given them pause and maybe given them a different perspective on our practice, beliefs, opinions, etc. So that is what I am here for. Just like you see other frequent posters here, you see me. But I am a dissenting voice. Would you prefer that dissenting voices be squelched? Does that help you to understand a little more Noni?

          • Suzi Q 38

            Thank you Proud Okie!

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

          Yes, I remember those 17 States and the District of Columbia that allow NPs to practice independently. Unfortunately though, you have 31 (because one State is considering whether or not to allow NPs in their State practice independently) States (one of them my home State of FL) that agrees with me and the physicians and their organizations being concerned about what would happen if NPs were allowed to practice independently. And the reason for the concern? Safety for the patients and the public community in general. The fact that the majority of the States and physicians and their organizations and I feel as we do make it a fact.

          Are the NPs that work in these States and the District of Columbia allowed to deliver babies, or is that left to the midwives and the OB/GYNs?

          I will be interested to see how long it takes before we start hearing even more about NPs being sued for malpractice when things go wrong. Especially as it relates to people who have chronic medical conditions that need constant monitoring by a physician.

          • ProudOkie

            Kristy, they have been doing it FOR YEARS. As I have asked to no avail, where are the maiming, the patient safety issue reports, the lawsuits. Where are they? Where in these states are they?

  • Greg Joachim

    “the word “Doctor” are no longer clear enough for people to understand which member of the health care team is caring for them”

    I couldn’t agree more with this. I’m a PTA and i’ve lost count of how many patients state that their “doctor” diagnosed them as having subluxed vertebrae or misaligned spine, only to find out they were referring to their chiropractor (naturally). Having a doctorate degree and being a “doctor” as most people understand the word are completely different, and people with their doctorates (whether a DPT, DC, or in religious anthropology) ought to stop asking to be called “Dr. _____”. I once turned down a job interview because the owner of the PT clinic requested to be called “Dr. Jen” when I spoke with her over the phone.

    • Mandy

      One can apparently obtain a PhD in Homeopathy now, and these master practitioners of woo are among the worst in always referring to themselves as “Doctor”. I would sooner be referred a patient who’d been treated by a “doctor” of religious anthropology than by a “doctor” of homeopathy.

      • querywoman

        Don’t forget the naturopaths!

    • ProudOkie

      Your post is a well stated opinion…..others feel differently and that’s okay too. Chiropractors are physicians. Research before you opine that they aren’t……

      • STG

        Greg Jooook’s post is not opinion…it is FACT. Chiropractors are NOT Physicians. They do not understand the depth of pathophysiology of diseases that afflicts the multiple organ systems nor can they treat them pharmacologically or surgically. With all due respect, I don’t think spinal/musculoskeletal adjustment will save anyone with ACS or who is in V-Fib or PEA arrest. So while the title they are given may indeed be “Dr”, they are far from being physicians. Trust me, I went to medical school with several former chiropractors who just wanted to know more…

        • ProudOkie

          Did you think I meant they are physicians of medicine? Nope. They are Chiropractic Physicians. Again, you might not like it and might have nasty things to say about it (and I might not like it) but it is what is…..

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

            The american organization of acpuncturists also calls their members “physicians”

            They must be correct if they say so, right? LMAO

          • ninguem

            Anybody can CALL themselves physicians. Or “doctor”.

            If all MD/DO physicians changed their professional credential to “ballerina”, pretty soon you’d see advertisements for “chiropractic ballerina”.

            What they’re trying to accomplish is obvious.

            That’s why I have long recommended, “real” MD/DO physicians (for lack of a better term) should identify themselves by the old term “physician and surgeon” with the name of their specialty “Family Medicine”, “Obstetrics and Gynecology”, etc.

            Even better, assuming certified, add “Certified by the American Board of Internal Medicine”, etc.

            For the chiropractors and similar, to use those terms, skates too close to the edge of the Medical Practice Act in most states.

          • Suzi Q 38

            “That’s why I have long recommended, “real” MD/DO physicians (for lack of a better term) should identify themselves by the old term “physician and surgeon” with the name of their specialty “Family Medicine”, “Obstetrics and Gynecology”, etc.”

            I personally think that this is a good solution to differentiate yourselves. I do not think that being snobby, though, especially in front of your own patients, is the way to go.

            Patients will feel comfortable going to whomever they choose. If I want the 10 or 15 minute version for something less complex or routine, I may prefer a certain NP that I have built a professional relationship with whose medical judgement I admire and trust. I would consider the time h/she spends with me and provides good care. I would also think about follow-up. Does h/she return my phone calls, or answer my emails regarding my care?

            I will be curious to see what happens.
            Of course, every few visits, I would want to check in with the MD. I consider the MD to have the full credentials to treat me.

            On the other hand, there have been times in my half centurion life that the MD was “out to lunch.” He meant me no harm, but he was so busy that he just did not care. When I pointed it out to him, in a form of a metaphoric “neon sign,” he got offended and egotistical and refused to do the test that would have given me the diagnosis in a timely matter.
            The midlevel (physical therapist) was the one that figured it out early. I should have given more weight to his diagnosis. Because he was not an MD (neurologist, at that), I did not.
            I went with the neuro, and this permanent partial paralysis.
            Even though the PT had the answer, I don’t think that MD’s should have a contest to see who is more qualified to say what I have.

            All ideas should be seriously considered. Learn to work together for the good of the patient.

            The NP’s are here to stay, especially in the state of California. My daughter will get her NP in a year, so I am looking forward to her future.

            Life is not fair. Get over it.

          • ninguem

            “Of course, every few visits, I would want to check in with the MD. I consider the MD to have the full credentials to treat me.”

            My father was chief of staff at a large multispecialty staff-model HMO. Hundreds of physicians on staff, covering several states.

            The rule, when he ran the shop, was every “X” number of visits had to be a physician visit.

            Over the years, that rule was scrapped over his objections. Us old-fashioned doctors I guess.

            I do a lot of chart reviews, I see patients misdiagnosed, and from time to time I’ve commented, “this patient has seen NP’s and PA’s for five years, by the records supplied, and in all that time, not one single physician visit has been documented”.

            And these patients have been to the big multispecialty Big Box places.

            Fine, except these places ADVERTISE to the public about the high quality of their DOCTORS, yet when I read the chart, the patient has not seen one of those doctors for years.

          • ProudOkie

            Agree completely. IF you aren’t seeing a physician, don’t advertise it. Fraud! And on the chart reviews – review the physicians too. You will find misdiagnoses there as well – we all know that.

          • Suzi Q 38

            You make some good points.
            It is unfortunate that they could not see their regular physician more regularly.

            I do want to point out that my board certified physicians have misdiagnosed several of my conditions. it can happen.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Do you know what’s even more amazing? It’s happening in SPECIALTY practices as well. My husband was diagnosed by a PA who works for a dermatologist, but he was told the dermatologist would actually perform any procedures. Well, imagine our surprise when the PA performed the procedure as well! The PA did a great job, so we’re not complaining, just surprised I guess.

            It’s all about money, money, money – the physicians have gotten lazy and sold out their profession, oh YES they have. They started pawning off their patients to NPs/PAs, then when outcomes were the same (or better) and the patients became comfortable with the NPs/PAs, all of a sudden the physicians are defaming the very people they trusted to take care of their patients!

            GREED IS GOOD! Greed invented our profession and now we’re here to stay!

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

            This is exactly right.

            It is the same deal with white coats. Nobody WANTED the white coat until it became a “status” symbol associated with doctors. Now all of a sudden every worker in the freaking hospital wears a white coat, including the janitor!

            I tell you what, if doctors started wearing purple coats and wizard caps, it would be a maximum of 5 years before all the pretenders also start doing the same thing.

            They want what doctors have, period. They want to be the big shots.

          • Caitlin

            Just don’t call a British or Australian surgeon “Doctor”. They’ll bite your head off for confusing them with those commoners ;-)

          • Suzi Q 38

            It is what it is.

        • ProudOkie

          Here is a quote from the aacp website – straight from the horse’s mouth –
          “The American Academy of Chiropractic Physicians (AACP) is a professional organization representing Chiropractic Physicians practicing evidence based medicine. Its mission is to preserve, protect, and promote chiropractic medicine and advocate for the authority to prescribe.”
          We might not like it (I personally don’t care) and some may denigrate them but that is the way it is.
          Why would someone attack another profession for being who they are and doing what they do?

          • STG

            I am not denigrating what you do or questioning the means with which you have chosen to make a living to provide for your families–unless you are telling your patients that you can cure things that you can’t with your body of knowledge. Hopefully you aren’t because that is harmful and immoral. Some of my friends visit Chiropractors for their back/joint issues and they do feel better…so, hey, fine by me. But the moment a chiropractor says he or she can treat high blood pressure, arthritis, diabetes, heart disease, or whatever with adjustment therapy–my blood begins to boil. I am not saying that is you, but there are those who do that. I don’t know how they sleep at night.

            All I am trying to say is that a physician is someone who studies, trains, and practices MEDICINE, which itself is based upon the diagnosis and management of disease in multiple organ systems of the human body through pharmacological or surgical means. Therefore, there is only ONE kind of physician. This is not a semantic issue at all. One can argue that a massage therapist “heals” by alleviating physical discomfort–they are usually very good at making you feel better. But would I call them a Physician of Massage therapy? Absolutely not. It’s like referring to the color “blue” as “white” when in fact “blue” has a defined wavelength in the visible spectrum whereas “white” is the confluence of all wavelengths in that spectrum. You can claim to be something, but that doesn’t make it so. Just like I am a doctor of medicine, but I would never refer to myself as a surgeon just because we have the same degree. I don’t have the skill sets or breadth of knowledge, training, and experience that a surgeon has. If simply stating this definition is seen as one profession attacking
            another–then we have bigger problems here. This is not a turf battle,
            this is just stating a fact.

            Using the AACP or state law as evidence justifying the use of the word “physician” to describe chiropractors is circular logic. Because they say chiropractors are physicians means that chiropractors are physicians does not fly. And frankly, the mission of the AACP in trying to advocate for prescribing privileges to chiropractors is very scary and troubling to me. There is a reason we go through so much schooling, training, and testing. It isn’t to give us the fancy title of Dr or to allow us the privilege of wearing the long white coat, but it’s to make us SAFE so that we know what the heck we are doing because there are so many integrated principles in managing a patient. Make no mistake, lobbying for the title of physician is meant to elevate certain professions beyond what they are not and it will only confuse the people that we are trying to serve.

            So no. I do not accept “it is what it is” because “it” is not true. Go through 4 years of medical school and go into Residency for 3 or more years. Then you can call yourself a Physician.

          • ProudOkie

            Believe it or not – I completely agree with you! I am not a chiropractor; I am a Nurse Practitioner. I think the term “physician” should be reserved for an MD/DO just as Nurse Practitioner is reserved for me. Makes things crystal clear. Thanks for the great post! I agree!

          • STG

            My apologies, I didn’t bother to read your other posts, but when I did, I saw that you are an NP. Thanks for opening the forum to debate and the expression of ideas though :) Clarity is so important–especially with healthcare. The more people are confused, the more frustrated they get…and then the more they lose faith in all of us collectively who CAN actually help them get better.

        • Suzi Q 38

          Who cares if we call chiropractors “doctors??”
          We call some professors with Phd’s “Doctors.”
          Oh, don’t forget the pharm D’s and psychologists.

          • DISQ_user9801

            If I have a medical emergency on a plane and the cabin crew asks over the intercom whether there’s a doctor on board, I don’t especially want an English Lit major or an Optometrist to step forward.

        • querywoman

          It’s all just words, anyway. English is a naming language. However, I have read articles about, for example, physicians in an emergency room assuming a “Dr. Somebody” could medically care for a sick child at home, but the doctorate was actually in something like the humanities.

        • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

          Just refer to yourself as a MEDICAL DOCTOR and get over it!

      • Guest

        In 2009 the Joint Commission decided that chiropractors (and optometrists!) could be called “physicians”. Next week they may decide that reiki practitioners and faith-healers can do the same. This doesn’t make any of them “doctors” in the commonly used sense of the word.

    • Suzi Q 38

      A dentist can be called “doctor,” so what is the difference?

      • Mike

        Some nurses with doctorates also want to be called “Doctor”. Now that’s confusing to many patients.

    • querywoman

      Sad, perhaps we need another word for “physician” now, but “doctor”
      is also an academic title.
      And for me, having spent a lot of my adult life in churches with highly educated clergy, the term, “Dr. Somebody,” often means a minister to me, though we usually call them by first names if we know them well enough.
      I also attended a very large church for years with physicians in it, and other “doctors,” but, “Dr. Somebody” usually means minister to me.

      • querywoman

        Oh, and folks, please don’t assume I automatically respect doctors of ministry. I have known some prize jackdonkeys in the ministry, just like in medicine, and some true sweethearts in both professions.
        As education becomes more and more common, “doctors” are growing like weeds!
        The word “doctor” is easier to say than “physician” for a person licensed to practice medicine. And that kind of “doctor’ needs to be distinguished as what he or she is!

    • Dave Mittman, PA, DFAAPA

      My PT calls herself Dr. until she meets you, as do all her colleagues. The audiologists in town does as does the psychologist, the OT and the PharmD.
      Why pick on the nurses?
      Dave the non-Dr. PA

  • Elvish

    Physicians had forgotten that being a specialist is the easy way to practice medicine.
    General medicine is the most challenging field in medicine, at least if you want to be a true General Practitioner or Family Physician.
    Anything, in any presentation can walk through the door; if you don`t realize the significance of the challenge then, you are not up to it.

    To let a professional, other than a rigorously trained Physician, practice General Medicine, is a crime and insult to generations of great physicians.

    NP`s/PA`s or whatever, can practice in any field of medicine, supervised, except General Medicine, where they should not be allowed to.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      It’s also a crime and insult to millions of patients… mostly a crime, I think…

      • Elvish

        It is a crime and most are okay with it because they are misinformed about the differences between Physicians and PAs/NPs.
        The sad thing is that people still think we are number one in medicine.

    • querywoman

      Absolutely, general medicine is the best and most challenging! I am older, have more complex problems, and see a range of well-qualified specialists now!
      Many times, in my younger years, I found the instincts of a GP the best! That was when specialists couldn’t or wouldn’t do squat for me!
      And one of the best I ever had was young osteopathic GP, fresh out of training, not board certified, but he is now!
      It’s possible that now I could get a good GP to continue most of my care, but I like all my specialists too much to let go of them!

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

        Querywoman,
        My Primary Care Physician of the past year is an Osteopathic doctor, and I really like him a lot.

    • http://twitter.com/ThirdCoastPA Matthew Edwards

      I am a physician assistant student and I just finished my Family Medicine rotation at a rural clinic and it was by far the most challenging rotation I have done yet. The doctor I was training under did everything from deliveries to palliative care with very little backup. This guy was true advocate for his patients and it was inspiring to see his dedication. His patients loved him because they knew they could trust him. I would personally be comfortable sending any of my family members to this doctor.

      I agree that Family Doctors have not been given the respect that they deserve. The breadth of knowledge needed to manage patients with multiple chronic diseases over all stages of life was overwhelming and humbling to me. Understanding the appropriate treatment for a given patient while taking into consideration their entire state of health and social situation needs a certain kind of clinical and human wisdom that only comes from years experience and study.

      As a soon to be PA, I truly respect what you guys do and I hope things get better for you.

      • Elvish

        I could`ve not said it better.

        I`ve worked with many PAs and they are best utilized by surgeons; general, ortho, neuro and other surgical specialties,

        Y`all will have plenty of work there and your help is and will always be truly appreciated.

        Good luck with your future endeavors.

  • http://www.facebook.com/profile.php?id=1338422225 Tom Garvey

    My instinct is that this article is generally correct regarding most nurse practitioners. Are there hard data tied to outcomes, though?

    • http://twitter.com/stevieaa1 Stephanie Augustine

      I can only comment on nurse practitioners who practice as midwives…the vaginal delivery outcome data for these NP’s are excellent, but of course, they can’t do a Cesearian if needed

  • http://twitter.com/Mbordelon Michele Bordelon

    You are missing the point. Nurse Practitioners, especially DNP’s are trained to address the issues you outline. The answer is an interprofessional approach to healthcare. Nurse Practitioners are trained to work collaboratively with all their healthcare counterparts – most importantly physicians. Rather than negate the contribution that ANP’s can make to healthcare, why not look at their contribution to healthcare to those who live in medically and healthcare professionally underserved areas (of which there are many in this country). Why not look at how you as a physician can utilize their skills to improve coordination of care? What have you to lose? I have worked with numerous healthcare organizations who cannot handle the primary care load with their physicians. They have recognized that if they fully utilize “mid-level” providers, they are more efficiently and better able to handle their patient’s healthcare needs. ANP’s aren’t physicians but they fill a vital need.

    The point being is “coordination of care”. No “man” is an island and if you continue to think that it is, the US healthcare system is doomed.

    • Guest

      “You are missing the point. [...] The answer is an
      interprofessional approach to healthcare”

      ——————————————

      Nice rant. Did you even read the original post? The author wrote:

      “…the answer cannot be to substitute care. We believe the answer is more physicians and more nurses working together in integrated, coordinated, physician-led health care team”

      • DrQuarde

        Probably the real problem with training more physicians is the eventual financial burden of salaries. Nurse practitioners seem to be a more financially reasonable solution. I am playing the devil’s advocate here and in no way saying i totally agree with the notion of training more nurse practitioners instead of medical doctors.

        The ideal solution is “…more physicians and more nurses working together in integrated, coordinated, physician-led health care team”… The mounting costs confronting healthcare will make this a mere dream. PAs and nurse practitioners will be the eventual solution to improving access to healthcare and reducing patient to provider ratios.

        • ninguem

          And yet somehow all the countries that are held up as our “betters” in healthcare organization……UK, Canada, Germany, France, the usual……all run physician models of healthcare delivery, and do not have significant numbers of PA’s and NP’s, if any at all………maybe I’ve missed it, but I don’t hear much about the NHS using NP’s for primary care.

          They run healthcare cheaper, claim better outcome,…..I know that’s debated……..with a much stronger primary care-led system. And I wouldn’t mind a British GP’s salary.

          I’m not claiming anything about who’s “better” or not, just saying that I’m taking the null hypothesis. Adding more midlevels (NP’s/PA’s)…….heck having ALL primary care done by midlvels……will not have any effect on the cost of care, and I can even see the cost going up as a result. I can’t see it go down.

          • ProudOkie

            Canada is overflowing with NPs. The United Kingdom does utilize them greatly as well. Just an observation.

          • ninguem

            Are they? I didn’t know that. Are they practicing independently, like a Canadian or UK GP?

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            ninguem – quit pretending like you’re so concerned about patient safety when we all know the only reason you’re commenting is because you’re concerned about your paycheck, job, etc. I’m sick of physicians pretending like they’re so concerned about patient outcomes, when just about everyone knows all they care about is COMPETITION, INABILITY TO NEGOTIATE HIGHER INSURANCE REIMBURSEMENTS, JOB STABILITY… Our profession was created by greedy physicians who wanted to make more and more money! Why do you think there’s an agreed upon bill before the Texas Legislature that increases the number of “midlevels” physicians can supervise from 4 to 7 PLUS they can supervise as many “midlevels” as they want if those said midlevels are treating medically underserved populations! Wow! That could be THOUSANDS of midlevels – how in the heck can a physician TRULY supervise 7 fulltime NPs/PAs, much less an unlimited number in rural areas?

  • Mandy

    So if next week they decide faith healers can call themselves physicians, you’re cool with that too?

    • ProudOkie

      You completely missed the importance of the “physician” title. State law allows or disallows various professions to utilize certain titles. So most states allow chiropractors to utilize the term “physician.” Thus, according to state law, they are physicians. The simplicity is almost stunning. If by some chance all of the faith healers in Oklahoma got together, lobbied the legislature and presented valid evidence that they should be called faith healer physicians and the legislature approved it and a valid faith healer board was created by statute – then, yes – that is what they would be. Ironically, I actually believe that only MDs and DOs should utilize the title “physician.” That is personal opinion. Whenever I refer to one of these professions, as another poster said, I always use the term PHYSICIAN. Not “doctor” or “provider”. It is a distinctive term that almost everyone can relate to and it sets their profession apart from all others. So, aside from all the obfuscation, the term is important. I hope that makes a little more sense to you.

      • militarymedical

        I agree. In conversation and written communication, I use “physician” to refer to MDs and DOs exclusively, while I use “healthcare provider” or “provider” to refer to NPs, PAs, midwives, bachelor’s-prepared RNs and other speciality personnel (e.g., physical therapists, dentists, psychologists, dieticians). There is some overlap, in that “nursing staff” can include NPs, DNPs, DCNs, RNs, LPNs and CNAs, and “healthcare providers” can be interpreted as including MDs and DOs. If we were all more consistent and careful about which words we used, there might be less confusion.

  • Dave Mittman, PA, DFAAPA

    As a PA for as long as you are a physician or longer I find your points simplistic and offensive. Let’s talk about PAs for a minute. We practice autonomously and always have. We run clinics and work with family physicians and many specialists as “junior partners”. We have a 50 year track record of seeing patients with complex problems, in hospitals, on battlefields, in offices in every setting. And you know as well as we do that those patients are treated well. I guess those 50 years get to be ignored.
    It would be better to embrace PAs and NPs as colleagues and say they can provide a huge percentage of primary care. Admit it. Work with us on some more training or a residency. But to reverse 50 years of practice and results of hundreds of thousands of clinicians seeing patients every single day is folly. We treat millions of patients every day. Ask the Air Force, Army, Navy, PHS, Indian Health, Coast Guard if their PAs and NPs can provide high quality primary care? Ask them? Ask the Institute of Medicine? You don’t want to hear the answers.
    Will all due respect, you don’t want a team, you want an “I’am the automatic boss and I have all the control”. That’s not a team, it’s an employer/employee relationship. Say that and be honest. Real teams don’t put down each other. If we are really that poor, we all would have known it by now. How about reaching out your hand in friendship instead of trying to tell everyone what to think, feel and do? I won’t hold my breath for your call although I do hope for it.
    Sad.
    Dave Mittman, PA, DFAAPA

    Livingston, NJ

    • ProudOkie

      Dave, See Matched M4s comment above. These are the future providers we are expected to work with in teams (although I am sure they would like “work for” better). I appreciate posts like that. More people see these posts than anyone can realize. They are permanent documentation of the disdain for us. Legislators, regulators, and most importantly, the public in general can see the vitriol with which they speak to us and the mismatch that person actually experiences when they see us in a private setting. Yes, as others have mentioned in this thread, the AAFP and other physician groups will have to take a different approach. Smugness, pride, humiliation, and wishful thinking by some only bolster our worth and our argument. Everything according to plan.

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

        When are you going to quit lying about Oklahoma NPs being “independent.” Every NP in the state of Oklahoma MUST sign up with a “collaborating” physician to practice.

        • ProudOkie

          I addressed that yesterday with minguem. Read through the posts. Thanks for the comment.

      • 3rd year med student

        Please, nurses and nursing midlevels are the BIGGEST bullies in the hospital. Hands-down.

        And you accuse physicians of vitriol? Have you looked in the mirror lately? Seriously. The worst people I deal with on a daily basis are nurses and NPs/NP students. The meanest Ob/gyn does not even come close to the douchebaggery that nurses exhibit toward medical professionals.

        Not only that, so many nurses are just plain lazy. They’ll mess up and seriously compromise care — then, when the resident/attending gets annoyed (with absolutely no mean words or language used), they get written-up. These are the “professionals” we work with on a daily basis. These are the ones who express the MOST vitriol towards others.

        • Molly_Rn

          OK, now we get it. You are angry at nurses. Thanks for making it plain. You need to find a diferrent profession. You clearly will not do well as a physician because you are so filled with hate towards nurses unless you practice some form of medicine that keeps nurses at bay. My husband was the medical director of a very busy Emergency Department and he loved and was loved by the nursing staff. They were a team and they helped each other to do their best. I worked 20 years in ICU/CCU and we loved our docs and they loved and trusted us. We also were a team and our roles complimented each other. So you either need to be a dermatologist who never does anything that requires interaction with nurses or you need to take your meds. I feel sorry for you because you must be miserable.

          • Isobel Winter

            No, he really does have a point. Nurses, as a group, treat medical students far worse than any other group. Behaving respectfully towards
            nurses is something that all medical students are taught as part of their curriculum now (not to mention the fact that actual doctors will
            warn you that it’s career suicide to be anything other than submissively sweet), but nursing students and nurses do not get the same lecture about showing respect to doctors and medical students. They are taught a defensive, combative approach to their MD peers. Respect is a two way street. It also seems like a huge number of non-physicians have huge egos to straddle in healthcare because they have a massive chip on their shoulder about not being doctors.

            People can point to competent nurses and incompetent doctors all they like – it makes no real point other than the fact that some nurses are amazing nurses and some doctors
            are rubbish doctors. It doesn’t mean that that same amazing nurse is an amazing doctor and his/her area of practice should start encroaching onto that of the physicians.

            That’s why we should just try to strive for professional equality in the form of mutual respect ie can’t we all just strive
            for excellence in our respective fields? I come from a research background where PhD research scientists and medical doctors would
            collaborate on projects. The research scientists never thought they could do the job of clinical doctors, and the clinical doctors didn’t think that
            they had the molecular and computational skills to be proper research scientists. Nobody had a chip on their shoulder about it. Nobody
            whined about not being respected because they weren’t allowed to do anything they wanted. Nobody took it as an accusation of being less
            than. They just saw themselves as having different, but complementary, roles.

            God,this whole debate is so petty. I honestly think that, deep down, it comes down to feelings of intellectual inferiority and superiority. Of
            course it’s hugely unpopular to speak of such things, because you instantly get branded an elitist.

            Everybody needs to feel that they are intellectually equal. People just aren’t, and although some nurses will definitely be smarter* than some doctors, they are the outliers and the mere fact that it is considerably more academically difficult to get into and get through
            medical school than nursing school will mean that as a group (again, speaking in terms of group averages, there will always be exceptions)
            doctors will always be more academically and intellectually inclined than nurses.

            *by smarter I mean intelligence in the classic sense of the word. Well aware that theories of intelligence have been extended into other, just as important types.

          • Molly_Rn

            Isobel, I am sorry if that has been your experience. I was never taught to be disrespectful of any one nor have I, in 20 years in critical care, experienced what you describe. In fact we would literally help all medical students and residents with stuff they didn’t know. We all have to learn sometime and are not born knowing. I think you are generalizing and that is never a good thing (as is saying never). And doctors are not always more academically and intellectually inclined than nurses. We are all different and have different reasons for choosing our professions. As I said team work and collaboration was the name of the game in the hospitals where I worked and in critical care an absolute must. So any generalization of physicians, medical students, nurses or anyone is inaccurate and unfair.

          • Guest

            Fair enough, I guess our experiences just differ. In regards to physicians being more academically and intellectually inclined as nurses – I said (twice) that this is a general rule and made a point of stating that that isn’t always the case.

          • Molly_Rn

            As I said I am sorry that you have met nurses that I am sure I wouldn’t want to work with. All professions have lemons.

          • sredman

            I am a nurse practitioner in Canada and feel sick to my stomach reading all of these comments today. Bullying, harrassing, childish comments…from all sides. It is all very sad! The derogatory comments are extreme and are not reflective of RNs, NPs, PAs or MDs as a whole. We all got into this to help people and (at least in Canada) the vast majority of us work together effectively to do just that. I am embarrassed by all of this and only hope that your patients do not find and read this thread.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Molly – before opening my practice, I worked side by side with physicians for years. They appreciated me and thanked me almost daily for my hard work. Those physicians are in the silent majority.

        • militarymedical

          Was your Mommy a Nurse Ratched who spanked you a lot? You have so much to learn, little one.

        • Guest

          3rd year med student, your hostility towards NPs and PAs strikes me as a little pathological and more than a little self-defeating. You NEED these people on your side in order to provide your patients with the best care possible. It’s not about you, or your ego, or about still holding a grudge against that nursing student who wouldn’t go out with you freshman year: it’s about being a cohesive part of a team which has top-notch all-around patient care at its heart. I hope you take Molly_Rn’s advice on board.

    • Mengles

      “What we are saying and what you won’t comprehend, is that we are trained well enough to provide primary care and we do know enough to know when to refer” — If that is the case, then why are PAs and NPs scampering off to subspecialties as well? I thought they wanted to close the primary care gap? Oh wait, that was just sympathy talking points for the media.

      • Guest

        Mengles – I own a minor emergency clinic. I’ve treated THOUSANDS of patients and I’ve saved the healthcare system HUNDREDS OF THOUSANDS OF DOLLARS – if not MORE!

        My clinic has been voted the #1 minor emergency clinic every single year it has been open. So, GET OVER IT, because some people would rather see a NP instead of a physician.

        If anyone makes derogatory comments about the care I provide, they had better be able to back up those comments in court. Because I’m not going to stand for it – I’ve HAD IT with people (physicians in particular) defaming my profession.

        • 3rd year med student

          Cool story bro. No one give a s***.

      • Dave Mittman, PA, DFAAPA

        PAs and NPs go to subspecialties because they pay more.

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

      Someone told me not too long ago that when it comes to the military the care now of the forces when it comes to medical care is going to corpsmen. Now whether that’s definitely true I don’t know. This is what they were told but they never told me who they heard it from. I thought that was interesting.

      • Dave Mittman, PA, DFAAPA

        Corpsmen have always provided very elementary care except on the battlefield where they are true lifesavers.
        Invaluable.

      • militarymedical

        Swell: an unsubstantiated rumor put out on a reputable blog gives it credibility. Where’s your sense of responsibility? Would you put out a similar senseless rumor regarding civilian healthcare (remember “death panels”?)?

        Corpsmen (aka medics) have always been the backbone of military healthcare, providing battlefield medical care at basic levels under extremely adverse conditions. Their training, today, is the equal of EMT responders (or better). The underlying theory is that higher-level providers (LPNs, RNs, DOs, MDs, NPs, PAs) are too expensive to replace if they become casualties at the frequency that medics become casualties themselves. A hard truth, but it’s there.

        Before you go spouting off the latest accusation against military healthcare, I suggest you do a bit of research first.

        • Caitlin

          I think she meant well, MM, and she did give the caveat “Now whether that’s definitely true I don’t know.” Hospital corpsmen do work on Navy bases too, in the clinics and hospitals, assisting the dentists and doctors and NPs and PAs, so with all the cutbacks lately I can see how a rumor like that might get started…… even though it is, as you suggest, as ridiculous and groundless as the “death panel” rumor. You’re obviously a lot better informed than most civilians here, and it’s great that you’re willing to correct falsehoods, but you didn’t have to growl so fiercely whilst doing so.

          • militarymedical

            Admonishment acknowledged. Mea culpa …

    • Mike

      “It would be better to embrace PAs and NPs as colleagues and say they can provide a huge percentage of primary care.”

      —————————————————

      But who’s going to see the low income patients? PAs and NPs snub Medicaid patients even worse than real doctors do. We’re adding up to 17 million new Medicaid patients and you lot are too up yourselves to serve them.

      From CNBC:

      while states are under increasing pressure to expand their Medicaid rolls under the Affordable Care Act (ACA), only 43 percent of doctors report that they currently accept Medicaid patients.

      At the same time, physician assistants (PAs) and nurse practitioners (NPs)—viewed by many as a potential solution to the primary care physician shortage—report that only 20 percent of them accept Medicaid, raising the question of whether Medicaid expansion will simply leave more Americans insured but with no one to go to for their care.

      • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

        I don’t know where this came from, but it’s FAR from fact. If physicians accept Medicaid and Medicare, then they LIMIT the number of those patients seen. I know several physician who claim they accept both, but only have around 5 Medicaid patients and slightly more Medicare patients. The vast majority of NP owned clinics accept 90% or more Medicaid patients and that’s why they’ve gone under or are barely breaking even.

        • Mike

          “I don’t know where this came from”

          As I said in my comment, it came from a CNBC article. Google “Medicaid Poised To Expand, But Who Will Take The Patients?” Thursday, 2 May 2013. Now, you provide me the source for YOUR figures.

          • ninguem

            Mike, that’s all I’m saying…..is what you just pointed out.

            Leaving aside the quality of care issues and who studied more and who knows what obscure diagnoses and who is a “doctor” and who is false advertising “doctor”…….

            For the sake of argument, stipulate that NP’s and PA’s are 100% just as good as physicians, and snap your fingers and give NP’s and PA’s 100% complete practice parity with physicians. They get paid 100% the same as physicians. They have a 100% unrestricted license. Hang out a shingle and go to work.

            I take the null hypothesis. Not a thing changes. All of the problems we have in healthcare today, will continue with not a bit of change.

            There is no “rural medicine” gene in the DNA of a Nurse Practitioner or PA. The problem is more work and less pay. The female NP’s will be even less likely to go rural. Certain realities of gender.

            The only factor that favors rural practice is the person is from that rural area, or trained rural.

            Allow 100% parity for the NP/PA’s, or don’t allow it, that’s another argument.

            But it won’t do a damn thing to fix any structural problem in American healthcare delivery.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            In the state of Texas, it’s impossible to tell whether a NP treats Medicaid patients or not, because all those visits fall under the PHYSICIAN’S name.

            A friend of mine owns a very busy pediatric clinic and her collaborating physician died suddenly. Those patients had NO WHERE TO GO, because the pediatricians in the area either didn’t accept Medicaid or limited the number of patients they treated. It took my friend a couple of weeks to find a physician who could even qualify as her collaborating physician, because according to the current laws in Texas, NPs can’t accept Medicaid patients unless their collaborating physician is on the panel. My friend usually treats about 50 patients per day and has for 8 years, yet NONE of those numbers are tied to her, but fall under her collaborating physician’s name. A physician who treats very few Medicaid patients, but is nonetheless on their panel.

            We have a bill before the legislature and that will change the way the numbers are tracked. Then we’ll finally be given credit for treating the medically underserved.

            BTW, I’m very involved with the Texas NP Business Association and I know how many of our members accept Medicaid. The vast majority of our members have practices that are made up of over 90% Medicaid patients. So, apparently I know more about this issue than CNBC. It’s obvious they’re not even aware of how the data is tracked.

          • mhedge

            As a practicing FNP, I can tell you that the data came from areas where NP’s are not defined as billing or accepting Medicaid. That is not accurate data… research it… you will find severe flaws in that report.

  • ninguem

    Thanks.

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

    Dr. Blackwelder: Thanks for the shout-out BTW. I have never suggested that nurses replace doctors. Ever. I’m not even advocating for independent practice for nurse practitioners. In fact, my point about ultimate responsibility should have made you happy: doctors HAVE been given ultimate responsibility societally and legally, and perhaps that’s as it should be. My point is that the depth and knowledge of physicians is not always needed. Let the doctors do the hard stuff. I’m totally with you on the need to work together. Let the PAs and NPs do the routine stuff. They should be there to help you and make your work more rewarding.

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

      The majority of people that come to see the doctor these days are patients that have conditions that are “hard stuff”. So as a result of this, the things that they have to deal with because of those conditions are not “routine” stuff. If a person has a long list of illnesses to deal with on a daily basis that complicates things even further, and because of this a doctor needs to be involved right from the start no matter what.

      • ProudOkie

        That is absolutely not true. Where did you even get that? Maybe a specialist. People with minor illnesses roll into clinics all over the country every day. You blindsided me with that one….

      • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

        Kristy – just how long have you worked in medicine? Obviously, you don’t have much experience! I own a super busy minor emergency clinic and the vast majority of patients who present at my clinic are there for minor emergencies – probably 99% of them. I have saved the healthcare system hundreds of thousands of dollars, if not more, during the short 3 years we’ve been open.
        Without my care, it’s quite possible that thousands of those patients would have gone to the ER or one of the over-priced (physician owned) minor emergency clinics where they would have been seen by a NP/PA (no doc on site) and paid more than double if they were uninsured or had a deductible. So, don’t spout off a bunch of BS you know NOTHING about b/c it makes you look like a complete IDIOT…just like your buddy Mengele.

        I know several REAL physicians who MAKE FUN of physicians who own/work at minor emergency clinics. A couple of them told me they didn’t attend school for “X” number of years to take care of minor illnesses. They are MORE than okay taking care of the complex cases b/c that’s what they were trained to do. Two of my good friends (who are very experienced internists) told me they would go brain dead if they had to take care of the types of cases I see all day long. THEY’RE RIGHT! And I’m more than thrilled to send them patients with problems that exceed my scope of practice. It’s a WIN-WIN situation for all of us. I think it’s interesting how the REAL physicians don’t have a problem with NPs.

  • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

    I’m a NP and you can bet I would never refer to myself as a doctor. Has anyone noticed the backlash against physicians? Why would I want to subject myself to that criticism?

    I don’t know very many physicians who actually finished a residency, so I can assure you, they never completed 11 years of education!

    Furthermore, you might be interested to know that in several countries, physicians attend medical school upon graduating from high school. They spend approximately 5 – 6 years in college/residency TOTAL before they can legally work as a physician in their country. If they choose to practice in the U.S., then they are required to complete an additional 2 years of a residency. Several of those countries have healthcare outcomes that are far superior to the U.S., so can someone please explain that to me? Also, there’s a bill before Congress that, if passed, will allow foreign educated physicians to come to the U.S. and practice for 3 years in a medically underserved area WITHOUT obtaining additional training. After 3 years, they’ll be awarded a green card and can practice anywhere they choose.

    • 3rd year med student

      Before you spout more BS, do you have any actual citations to support anything you’ve mentioned?

      You don’t know very many physicians who actually haven’t finished a residency? Then you know a lot of physicians who can’t practice medicine. You kidding me? The days of doing 1 year of residency and becoming a GP are looooooong gone — no hospital will give you privileges and no insurance company will cover your malpractice unless you’ve done a minimum of 3 years of residency. It’s tough even if you finish residency and are just “board eligible” — most places want you to be board-certified.

      I’m in my 3rd year of med school. This year alone, I will receive more training than any NP + DNP program in the US provides. That’s just from this year alone. I have tens of thousands more hours of training I need to complete before I’m allowed to practice independently.

      • http://twitter.com/hystericalogic Anna Rachel

        ^This. By the time I finish medicine, if you include post-grad, I will have completed 9 years of tertiary education in various ‘applications’ of the medical sciences (basic science/research + clinical medicine). That’s before I’m even an intern. Although I did a research higher degree which obviously extended my time (and not all medical students will do this), with the shift towards graduate-entry medicine in a lot of countries most physicians will have at least 7 years of tertiary education under their belt before they reach their intern year.

    • kjindal

      Wow you really have NO idea what you’re talking about.

  • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

    Ha! How exactly do you define supervision Mengles? I know many physicians who NEVER see their patients, they NEVER speak to their patients, they NEVER review a single chart – they let their PA do it while they sit on their fat a$$ and collect the reimbursements. Does that sound like supervision to you? Sounds to me like your peers have sold out your profession!

  • 3rd year med student

    Physicians need to man up and stop teaching NPs, DNPs, and CRNAs. Let them learn from their own — they will fall apart soon enough. We’ve seen CRNAs threaten hospitals when anesthesiologists refused to teach SRNAs. Why? Because they need physicians to teach them.

    So, just stop teaching them. Put your support toward PAs instead. They actually learn medicine during their training. They don’t waste time learning about nursing politics and doing watered-down MPH courses to earn a diluted “doctorate” in nursing practice. They actually have enough sense to realize how much breadth and depth of knowledge is required to safely practice medicine. And they don’t act like little children — they don’t act like they’re “entitled” to practice independently even though they get much better training than NPs do.

    Seriously. Stop hiring NPs and DNPs. Refuse to teach them. Hire PAs for your medical practice (AAs if you’re an anesthesiologist). This alone, I feel, will go a long way in deterring people away from NP school.

    • pediNP

      3rd year med stludent, I’m curious how you know so much about NP training? And why you are so anti-NP? Have you ever worked with one? I’ve precepted plenty of 3rd years like yourself when my physician partner dumped them on me, citing himself too busy to train them. All the students provided me with positive feedback, one telling me that he told his classmates they should all rotate with an NP.

      I’m not a physician. I don’t claim to be one. But I’ve been a nurse for 30 years, practiced in many settings, and have experience that you seem to discount.

      The solution to health care access is not drawing a line in the sand. We all need to work together, clearly something you have not learned at this point in your training. You have a lot to learn.

    • ProudOkie

      I am ALL FOR THIS. I have been condoning this at our professional board meetings for years. You and I agree here. STOP precepting us and STOP signing our supervision paperwork. Once you do this, we will have a solid case for independence. The profession that so desperately wants to supervise us, well, will not supervise us. Help us. Oh, and help us they will. Great idea grasshopper.

    • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

      I noticed you’re keeping your posts anonymous. Is there a reason for that? Actually, it’s a good idea, considering you might need a job one day and you might find that the owner of the practice is a NP.

      You’re an IDIOT.

    • Ben Auliff, PA-C

      Wow. Pretty ballsy for a 3rd year medical student who essentially knows NOTHING at this point in his or her career.

      • Jbsilva

        Looking simply at the preparation given from the degree itself, I actually would prefer working with an NP over a PA. An NP has better clinical skills, has more experience dealing with the responsibility of patient care, and has complementary skills to a physician rather than essentially the same knowledge but much less. A PA will eventually get the experience to become an able bodied health provider, but I’d find it hard to convince me that two years of post-graduate school after college, instead of nursing school, is sufficient to be responsible for much of the intricacies of patient care.

    • jeffrey trip

      Why can’t we just help people together.

  • civisisus

    Are there good sources of substantive data supporting – or refuting – Dr. Blackwelder’s assertions about qualitative differences between MDs & NPs?

    I’m referring to assertions like this one, particularly the latter portion of the quote:

    “Independent practice of nurse practitioners has not solved the primary care access issues or improved health outcomes at lower costs in those states that now have it…”

    I scanned the rapidly expanding # of comments but did not spot supporting information or links to same. My apologies if I missed it/them.

    Cites in reply would be useful, thanks

  • Dave Mittman, PA, DFAAPA

    You don’t have a clue. You rate looking for a fight.
    I gave up fighting with people like you about 25 years ago. Let it go.
    Look up the definitions of the words. And while you are at it why do you are so much. You know what I am, what is your dog in this fight?
    D

  • jeffrey trip

    I’m a nurse, and I love to help people! Woo Woo!

  • Santa Diego

    The only problem with Dr. Blackwelder’s article is that there is no empirical basis for his assertions, at least in primary care. He may be right, but there is little data (maybe none) to suggest that MDs produce better outcomes, at least in primary care. (Please read the 2004 Cochrane Systematic Review. Substitution of doctors by nurses in primary care. A main conclusion is that there is no difference in quality, but that nurses spend more time and have greater patient satisfaction). I I suspect that the decision makers will ultimately be influenced by data, and less by professional assertions about who is better than who.

  • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

    In Texas, it’s impossible to know how many NPs treat Medicaid patients simply b/c those numbers aren’t tied to the NP, but to their collaborating physician.

    The vast majority of NP business owners in Texas own clinics that treat Medicaid patients almost exclusively! Also, we (NPs) aren’t even allowed to treat Medicaid patients at our clinics unless the collaborating physician is on the Medicaid panel. One of my good friends who owns an extremely busy pediatric practice suddenly lost her collaborating physician (he died unexpectedly). She had to close her practice immediately until she found another physician. It took her a couple of weeks, because almost everyone she approached didn’t accept Medicaid!

    I’m not allowed to treat Medicaid patients at my clinic simply because my collaborating physician isn’t on their panel. Most of my patients are uninsured with a few Medicare and insured mixed in.

    Good LORD when are physicians going to appreciate us for what we do?

  • southerndoc1

    177 comments and not a peep from the OP.
    A small, but telling, indicator of why the AAFP is such a deeply dysfunctional organization.

  • http://twitter.com/RDBowman Rachel Bowman

    As a physician, I have worked with many very competent, intelligent, life-saving care-providing NPs and PAs. I think NPs and PAs are a vital part of the healthcare team. Team is the important word. We have to be a team. I don’t know if NPs and PAs can help the primary care shortage. I sure hope so. I love the NP that sees my family, she was an ER nurse for years and I trust her with my family’s health.

    However, I have some serious concerns about the influx of NPs into our healthcare system.

    In my residency training, many of my best instructors were PAs and NPs with years of experience. It seemed that most NPs I worked with had been nurses for many years BEFORE becoming an NP. (I can’t speak for PAs, my experience was more limited). Now, I serve as a preceptor for three different NP programs. All three programs are from reputable schools in my area. All of my students have been RNs who worked maybe a year or 2 as an RN, and then went on to NP school. I have been utterly shocked at the difference between their knowledge base and that of medical students. The growth of NP programs seems to have produced more young, less experienced nursing students. You just cannot possibly fit the amount of knowledge gained after 4 years of medical school + at least 3 years of residency into a 2 year NP program. The lack of training in pharmacology, microbiology and pathology is concerning. Even at the end of training, and understanding of basic pharmacology, which I believe is crucial to my everyday work, has been seriously lacking in most of my students.

    I know that this may not be the case everywhere, but I am concerned about many of the less experienced NPs I’ve worked with. The huge growth and expansion of NP training programs seems to have produced a younger, less experienced group of NPs. I hope they can still provide quality care, like the NPs in the 2004 cochrane review, but I just don’t know.

    • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

      I’m curious, are these new NP students attending online programs?

      • http://www.facebook.com/carolineinmobile Caroline Lyons de Freitas

        Most advanced nursing degrees from the most reputable universities all over the country are a mixture. The didactic course work is online however they must complete clinical hours in the field under the direction of both physicians and practitioners. There is no such thing as a purely “online” nursing degree.

  • mhedge

    I am not sure where you obtained this information but I would sure like to know. That is not been my experience in Mississippi.

  • eric sanders

    The only way NP or PA can help the primary care field is if we except that primary care clinic or urgent care is simply a clinic for triage. If we except this model then I will argue that this will not save a single penny in the health care system and will only make it more expensive. We need to provide incentives to medical students to enter primary care. Once the medical students choose primary care we need to ensure they are trained as generalist who are able to care for the fast majority of pathology seen by the general public without consulting out to specialist. But this is not what I see occurring, I see a massive influx of midlevel providers who are working in a team model or independently who are consult machines that is only costing the system billions.

    • http://www.facebook.com/mungo.stjames.1 Mungo St James

      You mean accept, not except.
      My longtime PCP works with another MD, 1 PA and misc staff. If my doc is too busy, I don’t hesitate to see the PA. She has made very helpful suggestions
      that neither the PCP or Pdoc discussed.
      Insurance nickels & dimes the primary care docs to low margins. It’s no surprise some are attracted to specialities.

  • http://www.facebook.com/carolineinmobile Caroline Lyons de Freitas

    Mr Blackwelder I think you need to read The Institute of Medicine’s Report The Future of Nursing: Leading Change, Advancing Health. There are 4 main recommendations they make:
    1. Nurses should be allowed to practice to the full
    extent of their education and training.

    *So for practitioners this would mean without physician oversight.
    2. Nursing education should be improved to promote
    academic progression toward advanced degrees.
    3. Nurses should be full partners with all health
    care professionals, including physicians.
    4. Improve data collection for workforce planning
    and policy research.

    There have been tons of studies easily searchable on CINHAL, PubMed, Cochrane, etc. that demonstrate the quality of care delivered by nurses as PCPs is equal to that of physicians and patients even prefer dealing with NPs. So the argument that the quality is inferior in terms of primary care is not legitimate. Furthermore its obvious this will reduce cost. What we need is an investment in the education of those who will be filling the role of PCP for the people that will be gaining access to the system and those who already live in Health Provider Shortage Areas where physicians refuse to work because they can’t make money.

  • lecelt

    I am amazed at the bigotry in this discussion. It’s really kind of shameful that professionals in any health care field should have such hatred, fear, ignorance…I’m not sure which. With the mess that our current health care system is in, I’ve got to question whether it should even remain under physician leadership since it has become a fiscal fiasco under their rule. Maybe nurses should step in and help to restructure the health care system. I don’t know any nurses who are in it for the money. Healthcare is a system in evolution. Physicians and surgeons evolved from alchemists and barbers. It wasn’t that long ago that physicians were bleeding people for just about everything, oh wait, they really kind of still do that… My guess is that the 3rd year medical student is just sorry he wasted (and is continuing to waste) so much money. Most patients that see PAs or NPs do so because they WANT to. No one drags them into the office. They usually schedule their appointments and walk into the office by themselves. No one twists their arms. If patients choose to see a PA or an NP over an MD, maybe the MD (or the 3rd year medical student) should wonder why, rather than demeaning and degrading the other professionals. I certainly would not want to see a health care provider that is as hateful and angry as some of the providers in this forum.

    • Guest

      “I don’t know any nurses who are in it for the money.”

      Then why do more nurse practitioners than doctors refuse to see Medicaid patients?

      • lecelt

        Data regarding nurse practitioner practice is often tied to their collaborating physician, so the tracking of NP activity is not always accurate. Some Medicaid insurance panels require that the NP’s collaborating physician be a Medicaid provider in order to allow the NP to see Medicaid patients. Some NPs see Medicaid and Medicare patients as “incident to” the physician services so the physician name is likely included in the data, not the NP. I don’t think the statistics accurately reflect reality. I think there are too many variables that skew that data. There are many states that reimburse NPs at a lower rate than physicians for the same services for Medicaid patients. While I say that “I don’t know any nurses that are in it for the money,” I will also say that I don’t know any nurses who are independently wealthy and can afford to run a practice made up exclusively of patients with insurances that are poor payers. Nurse practitioners, just like their physician colleagues, have to cover their overhead. I’m sure many NPs have limits on the number of Medicaid patients they can see, as do many physicians. However, I do know many NPs that work in underserved areas and in clinics that serve the poor.

  • PatriotMissile1989

    As a patient, I honestly would prefer a nurse practitioner-led medical team in which the physicians were specialized experts, but the manager of the team was the nurse-practitioner. They don’t order as many scans so it’s cheaper for me.

    There’s not a lick of evidence that nurse-practitioners produce inferior outcomes to medical doctors.