Nurse practitioners should be released from their arbitrary bondage

As of early April, you can walk into Walgreens in 18 states (plus D.C.), and along with a gallon of skim milk, a pair of photo mugs, a six-pack of toilet paper, and a flu shot, you can meet your new primary care provider, get your cholesterol checked, pick up your statin, and schedule a return visit. That primary care provider will not be a physician but a nurse practitioner (or a physician assistant, but that’s for another article). Those states, and now Walgreens, have recognized that nurse practitioners can handle a lot more than antibiotics for urinary tract infections: They can practice primary care just fine without physician oversight. And it’s a pretty smart move.

Lagging behind are the other 32 states (this map lays it out), in which nurse practitioners are supervised to varying degrees by physicians, the scope of their practice restricted by laws that vary from state to state. In some states, nurse practitioners can’t enroll a patient in hospice, order a wheelchair, or prescribe certain medicines without a doctor’s signature. This is true even when it’s impractical geographically and financially, not to mention belittling. Nurse practitioners in a number of states, including Connecticut, Nevada, and West Virginia, are currently pushing for legislation for the right to practice independently and improve access to care.

The time is ripe: Despite new medical schools designed to attract students interested in primary care, the long dwindle of interest in the field has left a gaping hole, and it’s growing. When an additional 32 million or so Americans are covered through the Affordable Care Act next year, the primary care physician shortage could be catastrophic; it’s estimated to climb as high as 45,000 too few primary care physicians by 2020. Anyone who’s looked for a new physician recently has probably heard some variant of this: “The doctor isn’t taking new patients, but you can see the nurse practitioner or the physician assistant.”

When I called Linda Pellico, associate professor at the Yale School of Nursing and director of the Graduate Entry Prespecialty in Nursing program, she didn’t mince words. “Lifting the barriers on the scope of practice will solve the health care dilemma,” she said, pointing me to the nearly 700-page 2010 report by the Institute of Medicine called “The Future of Nursing.” The document, co-authored by Donna Shalala, recommends that nurse practitioners practice independently, without restrictions, to the “full extent of their education and training.”

The nurse practitioners I’ve worked with as colleagues (I’m a primary care doctor, and I’ve practiced in clinics in Baltimore, New York, and Connecticut), and those who have taken care of me have been pretty awesome. When I was pregnant, I saw a middle-aged lanky nurse midwife who had a wry and down-to-earth sense of humor. He didn’t exude that sense of impatience that you get with so many doctors, that feeling that you’re holding him up from something more important. When I have questions about my very old patients, many of whom have dementia complicated by agitation or insomnia and who are not responsive to my usual bag of tricks, my go-to person is not a psychiatrist—she’s a gerontological nurse practitioner.

For some doctors, a larger number of independent nurse practitioners would be great news: John Schumann, a general internist who runs the University of Oklahoma–Tulsa internal medicine residency program, told me that he welcomes all hands on deck: “We should be happy when people from other career lines want to work in primary care. Primary care is hard and undervalued, and doctors should not have a monopoly on it.”

So I was surprised when some of the most open-minded doctors I know hesitated before offering their take on the issue. Most echoed some of the concerns of the major physicians’ organizations: If collaboration with a physician becomes optional, will nurse practitioners know when to ask for help? And if primary care doctors need to attend four years of medical school and three of residency, can just three years of nurse practitioner postgraduate training create competent clinicians?

But making a head-to-head comparison is tricky. Unlike the broader and basic science-heavy education of medical students, nurse practitioner students (many already having a few years of nursing experience) get practical right away and select a specialty— such as pediatrics, geriatrics, anesthesia, family, or midwifery—immediately upon beginning their training. During the corresponding years, medical students are studying subjects like embryology and biochemistry and learning the basics of how to talk to patients. Once nurse practitioners graduate, some opt for a year of additional training in a nurse practitioner residency program. (Newly minted doctors at that point will have chosen a residency specialty and will embark on at least three more years of training.) A few more years in training and nurse practitioners can earn a doctorate in clinical nursing—a DNP, which the Institute of Medicine report recommends for all advanced-practice nurses as of 2015.

Meanwhile, medical training is getting a makeover, so the difference between nurse practitioners and doctors—at least in terms of years of training—is lessening. The 100-year-old paradigm is on the chopping block in many medical schools, and some schools and hospitals are already cutting the length of med school and residency training. (Let’s not even get into the outdated prerequisites for med school. Suffice it to say that I learned more about caring for patients by reading Chekhov than studying organic chemistry.) According to Ezekiel Emanuel, doctors’ training could be shortened by about 30 percent. Medical-school graduates of six-year training programs (which collapse the usual eight years of college and medical school into six) don’t do any worse on board exams; some schools already offer a three-year track. For internal medicine residency, Emanuel argues that three years is unnecessary; many programs have long offered two-year “short-track” options for residents eager to jump into a specialty, so why should training for primary care be any different? In my primary care residency, I spent many months on inpatient and intensive care unit rotations. This made more sense in the mid-1990s, when most primary care doctors still rounded on their own hospitalized patients. Nowadays, with hospitalists running many of the inpatient wards, many primary care physicians are becoming almost exclusively outpatient.

The Institute of Medicine report highlights a number of studies that show that nurse practitioners provide as good care with as good outcomes as primary care physicians, along with high rates of patient satisfaction. In one of the most-cited studies, 1,316 mostly Hispanic patients were randomly assigned to see either doctors or nurse practitioners, and the outcomes of patients with diabetes and asthma were about the same. But the trial only lasted six months, which is a pretty short period of time in primary care for drawing conclusions about disease management and the patient-provider relationship. Whether you can extrapolate these findings to patients of different ages and backgrounds and to all of the chronic conditions that surface in primary care (and Walgreens) remains unclear.

Primary care is not an easy field to master; the breadth and depth of knowledge is vast, unlike the narrower world of the shoulder specialist, who only sees patients with shoulder problems. Sure, every now and then there’s the glamour of cracking a diagnostic mystery case, the chance to dredge up some obscure and critical fact buried in our overloaded brains, but most of the time it’s like this: We talk. We listen. (Hopefully, we listen more than we talk.) We treat common illnesses and try to prevent chronic ones. We learn about where our patients live, what they eat, who they talk to, how they get around. We listen to the patient whose marriage is on the rocks and relate this to her elevated blood pressure. We coordinate care and help devise a plan when multiple specialists are giving different and sometimes contradictory recommendations. We make a lot of phone calls and answer a gazillion emails. When we’re not sure about something, we look it up, or knock on a colleague’s door, or call across town or across the country. And because primary care is all of these things, an ever-evolving conglomeration of medical knowledge and systems and empathy and integrity and creativity in problem-solving, this is precisely why it’s good to mix it up and reap the benefits of some nurse practitioner-doctor hybrid vigor.

This is why I think nurse practitioners should be released from their arbitrary bondage and do what they are trained to do, what they’re board-certified to do, and what many do so well: take care of patients and collaborate with physicians because they want to, not because they have to. Nurse practitioners and doctors should welcome each other’s perspectives, experiences, and abilities. As physician assistant and researcher Roderick Hooker told me in an email, “America is a nation of innovators and the advancement of medicine and nursing are no exceptions. Nurse practitioners and physician assistants are part of the social experiment to deliver healthcare in beneficial and effective ways. The independence of [nurse practitioners] is merely another step in this social experiment.”

It’s time to unlock the gates to the primary care club. There will be plenty of patients for everyone.

Anna Reisman is an internal medicine physician who contributes to Slate, where this article originally appeared. She can be reached on Twitter @annareisman.

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  • http://twitter.com/ViVVish00 Vishal Chauhan

    Great Article. I do agree with the need of handing over primary care to Nurse Practitioners and Physician Assistants as the length of training and cost required to educated them is minimal in comparison to a Physician. At the same time, if this is the direction our country is choosing to go we need to actually trend out Medical Students away from primary care and towards hospital medicine/specialty care. Everyone needs to practice at the “top of there license”. – Fourth year medical student matched into Internal Medicine.

    • Mengles

      I could be wrong, but I don’t think that’s what Dr. Reisman was advocating, with regards to “handing over primary care to NPs and PAs.”

      • http://twitter.com/ViVVish00 Vishal Chauhan

        I agree that Internal Medicine for all intents and purposes is considered primary care but the trend is shifting. Many internal medicine physicians who choose to not pursue fellowship are leaving residency as Hospitalists, or essentially physicians who practice hospital based medicine, which as far as I am aware Nurse practitioners are not trained to handle. I am not saying that I agree with the shift that is occurring in increasing NP autonomy but i am not saying that I disagree with it either. I am too early in my training to really make a proper judgement. All i am observing is that healthcare providers are all being forced to practice at the top of there license and if we have decided that NPs are the solution to our primary shortage then yes future physicians need to be shifted into either more hospital-based acute care environments or outpatient specialty care.

        • Mengles

          Sorry, to burst your bubble but there are ALREADY Nurse Practioner hospitalists as well. Thus, although you may agree that primary care can easily be handled by Nurse Practitioners, but not Hospitalist Medicine, that decision is being made by government and hospital business types, not by medicine, so it wouldn’t matter where you were in your training. Also, again sorry to burst your bubble, but NPs are already heading in to specialty practice as well as they don’t wish to do primary either, whether that be Derm (there are NP Derm fellowships), GI (Hopkins Med has a NP GI fellowship program), etc.

        • Caitlin

          “Hospitalists, or essentially physicians who practice hospital based medicine, which as far as I am aware Nurse practitioners are not trained to handle.”

          See the KevinMD post by Gene Uzawa Dorio, MD: “Increasing the role of nurse practitioners in the inpatient setting” [April 12, 2013]

          • Mengles

            Right on the money, Caitlin. I’m curious as to whether Vishal believes NPs as hospitalists is an example of NPs practicing at the top of their license, considering that they already are.

  • Elvish

    This is a joke !
    We always choose the easy way out, always choose the cheap way out.
    Instead of soldiering on and trying to produce quality physicians, you choose the easy way of not going to med school and going to an NP or PA school in order to practice medicine.
    Look at Canada and New Zealand, they only take U.S.-BC Internists and family physicians, they don`t take PAs nor NPs !
    More over, instead of having a 6 year medical school curriculum, you want to shave a year off the deficient 4 year curriculum !!
    Performance on Board examinations, never was, never will be a measure of how good a physician is.

    This is disastrous ! You will have non-physicians deciding whether a patient should be referred to a cardiologist or not ? Non-physicians managing heart failure ? non-physicians managing thyroid disorders ? non-physicians managing arrhythmias ? non-physicians managing stroke patients ? non-physicians managing coronary heart diseases ?
    non-physicians reading ECGs ? An average internal medicine graduate is not proficient enough to do so !
    Who would do the stress tests ?

    Do you think that medicine is all about guidelines ?
    Why don`t we kick everyone out and have computers triage and manage the whole thing ?? Some are trying to study that as well !

    • http://www.facebook.com/ed.mathes Ed Mathes

      PAs have been used in the Canadian Armed Forces for years, in Manitoba ProvInce and, recently (~7 yrs), Ontario Province.
      Ireland, England, New Zealand, Australia, India, all have introduced PAs with varying degrees of acceptance and success.
      paS managing heart disease, diabetes, etc etc etc. Every day. Successfully. Outcomes data is available.
      One would think, after 50 years of proactice, PAs would be better understood by the physicians they work with…. or not. I’ve been around long eenough to remember specialists, including cardiologists, who refused to accept referrals from PAs. And you are concerned about patient safety? Really?
      Come spend a day with me…..

      • Elvish

        With all due respect, you still do not get it.

        You can work in a hospital or a practice assisting a physician; the problem is that PAs and NPs think that assisting a physician means you manage a patient on your own.

        Those cardiologists are right in refusing a referral from a PA or an NP; an Internal Medicine or Family Medicine physician can manage most of the heart issues, except for interventional cardiology.

        Give it some time, and soon PAs/NPs in specialty groups will say internal medicine and family medicine physicians are not qualified to manage our patients and they will say that they need to be paid more than those physicians.

        It happened with CRNAs before, they said they deserve to be paid more than “primary care” physicians.

        In England, not everyone is a consultant, i.e., an attending, all spend years and years working as specialty registrars-GP or specialty- and if they are strong enough, maybe they can become consultants.

        But here, we continue watering down medicine until it becomes an online degree, oh, my mistake, it is an online degree for NPs !

        This article is not thoughtful nor progressive, it reflects lack of insight and wisdom !

        • ninguem

          Wouldn’t be unheard of.

          University neurologists in my area do not want referrals from physician FP’s, let alone NP’s.

          Their position is, much of their referral base is disease more appropriately managed by local community neurologists.

          So a referral to them has to come from a neurologist.

      • Caitlin

        Australia doesn’t have anything even close to an established framework for Physicians’ Assistants. There was a very limited trial of the idea in the state of Queensland a few years ago, where five experienced US-trained PAs were recruited to practice at four different sites for 12 months, interestingly there were concerns at the time from nurse practitioners that the addition of PAs might complicate the establishment of the fledgling NP profession!

        It is certainly something being closely looked at though. The Australian Health Ministers’ Advisory Council just issued a report into “The Potential Role of Physician Assistants in the Australian Context” in August last year, I will try to provide a link to the .pdf version here but if that doesn’t work just Google “hwa-physician-assistant-report-20120816.pdf”. NPs might find it of interest as well. Cheers.

    • LastoftheZucchiniFlowers

      not sure where you practice, elvish, but around here the ccu rns (NOT even NPs) can read an EKG (and correlate) like commandos. They do this day in and day out and are quite frankly, amazing. In my field we have a way of denigrating other physicians who are NOT in our ‘elite’ specialty “non-dermatologist physicians”. We MUST STOP defining each other by what we are NOT. It’s inaccurate, derivative and ultimately reflects our own false bravado but not much else. Medicine is changing and we need each other. If a colleague (MD, NP, DO, PA, et al) is unsafe, do not permit them to comanage your patients; otherwise, the motto should be “all in”.

      • Elvish

        Yeah, let a nurse interpret a 70 yo man`s stress ECG.
        Not recognising the problem, does not eliminate it.
        The broader the field, the more challenging it is.

        Remember, anything, in any presentation can walk through the doors when you work in family practice or urgent care.

        It`s not like Radiology or Dermatology. It`s a bit more challenging.

        Once up on a time, I did a rotation with a general surgeon, and he used to take his ECGs to one of the internists. The surgeon was amazed by the internist`s skills. Later on, I rotated with that internist who used to take his ECGs to cardiologist, who was trained in England, and he was amazed by the cardiologist`s skills.

        Someone who does not interpret ECGs regularly, might be amazed by someone who could spot LBBBs.

        I hope you get my drift.

        • LastoftheZucchiniFlowers

          el – I get your drift. I regret that you failed to get mine. We ALL started as generalists and hopefully have not forgotten the sheer volume of the clinical fund needed to do good medicine there. CRNA-first assists, CNM’s, NPs/DNPs/PAs: they’re all here to stay my friend. Get on board now…..or later. You and I have both seen and cringed at medicine/surgical colleagues who made us ask…”how did this cretin EVER get/into or out of med school?” I suspect we both know the answer to that. Now, we have two NPs in our practice who we personally trained. We decided over ten years ago to give our standard ‘primary care derm lecture’ in the local university’s (then fledgling) NP program as a favor to the dean’s husband (a colleague of ours). Two very bright students in that program (then RNs with ten and fifteen years diverse, inpatient experience, respectively) expressed intense interest in Derm. Back then it was somewhat of an ‘experiment’ but it has paid off in every way. They round on our LTC patients and do all minor surgery. We would be hard pressed to do without them as they’ve added to our bottom line quite nicely and are competent to the degree we require. They don’t do z-plasty or Moh’s, naturally, as that is not within their scope. But we reward them accordingly and found that we did not need a fourth derm to augment our too busy practice at a time when it was all but a fait accompli. We are even thinking of adding a pt PA next year for a satellite office as there are several EXCELLENT ones in our area.

          A friend (general surgeon’s) wife is an acute care NP who worked ER for years after cutting her teeth in the CCU with those confounding ‘stress’ EKGs you referenced. You must realize that some people are simply gifted at what they do – and not just at finding rabbit ears or delta waves…….

          best to you

          • Elvish

            Okay perhaps I`ve missed your point.

            Let me ask you this, why would we let non-physicians practice primary care medicine independently and not let them do the same with other medical specialties ?

            1- Wouldn`t it be easier for them to manage patients after they have been worked up comprehensively by Internal medicine physicians, family medicine physicians or paediatricians ?
            2- Do you think it is wise to do so ?
            3- Can you imagine a whole field managed completely by non-physicians ?

            4- Can you imagine specialty-NPs managing patients independently ?

            -5 Would you trust an NP to manage breast cancer patients or leukaemias ? I`ve done years of cancer research and the amount of literature is overwhelming !

            -6 Who will teach medical students and train residents in primary care medicine ?

            The reason people like the author are suggesting independent practice for non-physicians, is to solve the problem of physicians shortage, but there is shortage in all specialties, when will we stop ?

            We have to clearly and transparently identify the role of non-physicians, since physicians are the guardians of medicine. Then, we can set up a system where we utilise all man power.

            You don`t have to answer the questions but just think about them.

  • 3rd year med student

    I’ll be okay with giving complete free rein to NPs the same day we give complete free rein and independent practice rights to 3rd year medical students.

    Rationale — by the end of 3rd year, med students get more basic science training and approximately 4000 hours of clinical training. That’s more than most nursing midlevels get.

    So, if you want to give free rein to NPs, you should have absolutely no problem lobbying the government to give free rein to M3s. I’m looking forward to hearing your support for this.

  • Mike

    My sister in law has watched every single episode of “House” and “Grey’s Anatomy”, religiously. I’m pretty sure that in Ezekiel’s world that’s enough for her to open up her own private medical practice now.

  • http://www.facebook.com/johnckeymd John Key

    This is nuts, and somebody needs to say so. It’s true that “head to head comparison [of NPs] to physicians is difficult–yes it is because there IS no comparison. Even Ezekiel Emanuel’s dumbed-down primary care MD will still have a much larger fund of knowledge that all but the most advanced nurse practitioner.

    Yes, I have worked with many nurse practioners and valued every one of them–but they were not physicians, and the difference showed itself often. There is a lot to be said for knowing all of that physiology and microbiology and all the other tough training. It just isn’t true that such background is all unnecessary educational overkill.

    There is still, and always will be, a valuable role for the excellent diagnostician in primary care, despite their limited numbers at this time. If their tribe does not increase, we will all be the worse off for it. It was always explained to me that the origin of nurse practitioners was by selecting excellent nurses to work using established protocols in limited diagnostic groups. To me that is still where their function is excellent. But for soft-headed central planners to decide that any NP = any MD, it just isn’t so.

    Sowing the wind always reaps the whirlwind.

  • Mengles

    Dr. Reisman seems to have a very bad case of Stockholm’s Syndrome, to where she goes to the point of degrading medical school education. This post seemed more like a listing of talking points rather than critical analysis of each (see Dr. Karen Sibert’s articles in contrast). Only Dr. Reisman could unquestioningly believe in decreasing the years of residency, decreasing the years of medical school, etc. as somehow being good things.

    There is a reason we don’t “get practical right away” Dr. Reisman – it’s bc medicine is complex and getting even more so, even though you may not feel that way. Your way breeds cookbook and algorithmic medicine. Only a naïve person would believe that basic sciences esp. in physiology and pathology is a waste of time. What I think is interesting is that Reisman unwittingly and unquestioningly posts every talking point espoused by those whose sole aim is trying to only cut costs and pander to special interest groups – such as decreasing years of residency and medical school, etc.

    She posts studies and believes without hesitation that NPs are equivalent to primary care doctors even though those studies had more holes than swiss cheese in study methodology, high number of confounding factors, funding by nursing groups who have an obvious interest in the outcome, etc. and had the backing of a former Clinton official who if you google her, is well entrenched in the nursing lobby.

    All this is not surprising to me as Dr. Reisman posts on the far left liberal blog – Slate. This is the same blog in which an article by a liberal blogger posting “America’s Doctors Are Paid Way Too Much”, passes as journalism.

  • trinu

    I’ll never understand why people think we should hand our primary care over to nurse practitioners and only see MDs/DOs when we need specialists. It makes much more sense to see a nurse practitioner for say derm and see a physician for primary care, simply because to do derm you only need to know about skin, whereas primary care requires you to know about the whole body.

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

      “simply because to do derm you only need to know about skin”

      Umm sure…because diseases of each body system are caused, exist, and have effects purely within that given system….

      (NB: not at all even kind of slightly true)

      • trinu

        There’s a difference between knowing the other systems only as they relate to the skin and knowing the other systems at the level necessary for primary care, and that’s quite a big difference.

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

          If by that you also mean that it’s important to know dermatological manifestations of diseases from other systems as well then sure, but that’s not what you originally said. If that’s what you meant then you should have been clearer.

          • trinu

            It was implied and you are just trying to pick nits.

          • Guest

            No need for any picking of nits here, I understand a reader above might have some leftover permethrin that’ll do the trick ;-)

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

            No it wasn’t. You said to do derm you only need to know about the skin. No implication there whatsoever.

          • Guest

            Those of us who are not dermatologists or affiliated with derm understood exactly what she meant.

    • E.B,

      In my daughter’s case, it was an NP at our PCP’s office (we never get to see the actual doctor) who (after unsuccessfully treating her for “scabies” [!!!]) referred her to a Derm, and a Derm who suspected the metabolic disorder Porphyria was causing her skin and scalp lesions — and confirmed it through testing.

      If we’d been stuck with an NP as a Derm as well as for a PCP, we probably would still be slathering my daughter with dangerous and ineffective insecticide creams to this day and we would still have no idea what was wrong with her!!!

      The skin is not the only organ of the body a good Derm knows about, not by a long shot!

      • ProudOkie

        Where was the PCP that was supervising the NP you saw? Do they not review each and every referral and make sure the mid-level is making appropriate referral decisions? Did they not review the prescription for the medication and was it prescribed more than once? The new generation of team leader (physician) should be reviewing each and every instance concerning issues such as yours always and often throughout the work day. If your daughter was prescribed the “common” scabies medication, it should not have been prescribed very frequently. The team leader needed to pick up on this. Hmmmm……just wondering.

        • E.B,

          I didn’t even know the two doctors we usually ended up seeing at that practice, weren’t even doctors, but nurses, until the Dermatologist mentioned it, after our daughter was referred to him! Turns out there was only one real doctor at that practice, but I don’t think we ever saw her, once!

        • Mengles

          Proving even more that NPs and PAs need supervision by a physician and at the very least don’t know when to refer.

          • ProudOkie

            Actually what this proves is the team leader can never supervise every patient all of the time. The physician would not have referred the patient either. Please who are you fooling? Anyone who is a provider on this blog knows that so you can only fool the non-medical people. But if that is what you say you want to do, then get your butt in there and spend all day long supervising scabies. You want it – you got. My paycheck and hours are the same. And by the way, you wouldn’t have been able to diagnose porphyria from a skin rash either – geez – unless the mother told you the kid howled at every full moon. And then you still wouldn’t have known.

          • Mengles

            How do you know the physician would not have referred? Um, even a medical student at the end of first year learns what porphyria is and knows what it is. Sorry, that you didn’t.

          • ProudOkie

            Yah you are right. I need to just understand that if a patient walks into any physician clinic with a rash caused by porphyria that they would ALL say, “look, that’s porphyria!”. And if they walked into any NP clinic they would ALL say, “Hmmm, not sure what that is.” Pssst……your insecurity is showing and your need to be right is glowing.

          • Mengles

            No it’s called actually looking at the rash and looking at the morphology. Not surprised you would expect the patient to save you. This isn’t a multiple choice exam.

        • LastoftheZucchiniFlowers

          I believe that in most states (at least here) the charts of NP managed patients do not require co-signature like those of the PAs. That is, I believe, a function of the fact that PAs are made in affiliation with Schools of Medicine and NPs are not. Nonetheless, the collaborating/supervising doc co-signs a rather small portion of his NPs charts.

      • Mengles

        Yup, can you imagine if you were still continuing to put permethrin on your daughter? It is very carcinogenic. But I guess for some midlevels, it’s just collateral.

        • LastoftheZucchiniFlowers

          citation re: permethrin carcinogenicity pls?

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

        E.B. – your daughter’s case is RARE. Thank GOD that NP referred her to a dermatologist! Do you really think a physician, other than a dermatologist, would have been able to make that diagnosis? NOT BY A LONG SHOT!
        I worked SIDE BY SIDE with board certified physicians for YEARS and I can tell you, they would NOT have been able to make that diagnosis.

        • Mengles

          Yes, I’m sure you’re able to evaluate physicians level of knowledge well. Her daughter’s case may have been rare – but that’s when medical education counts the most and when people’s health on the line counts the most.

      • LastoftheZucchiniFlowers

        In derm we know that the dx of scabies should ALWAYS be confirmed by a skin scraping/microscopy which will reveal the sarcoptei mite and its scabala. In the absence of those you one cannot dx scabies. PS – permethrin cream (made from chrysanthemum) is quite safe (unlike Lindane). Is the porphyria familial?

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

          LastoftheZucchiniFlowers – you need to get into the REAL world. Do you really think that we perform skin scrapings on every person we suspect is infected with scabies? I treat scabies on a daily basis and guess what – I’m not doing skin scrapings! Somehow my patient’s symptoms magically resolve!

          I work on the front line and I’m doing just fine! I almost have to laugh when I read all these comments by medical students who don’t have a clue about what goes on in the real world.

          • LastoftheZucchiniFlowers

            Ms. Malowitz – It’s been almost 30 years since I was a medical student and having been on those ‘front-lines’ for over three decades, am fully conversant with the ‘real’ world, as you quaintly refer to it. Moreover, If you are treating scabies without a scraping to confirm your dx then I am sorry to tell you that you are not providing the standard of care to your patients. Are you working in a dermatology practice? The Ddx for papular urticaria is not simple and if you do NOT scrape to confirm the presence of mites (which takes seconds and leaves no doubt to causation) and simply ‘treat scabies on a daily basis’ – then I’m sorry to tell you that you’ve just been lucky though and not very smart. Some would consider your attitude as lazy and the glib nature of your retort is precisely what physicians worry about vis a vis. midlevel competency (or lack of them – if you are even a midlevel). While you assert that you’re doing ‘just fine’ I submit that it’s not about you, but your patients. Better wise up.

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

            So…what about all those thousands of physicians who are treating scabies without doing a skin scraping? You MOST DEFINITELY are NOT practicing in the real world of PC…maybe the real world of derm, but not PC. And these idiots on here who assume we keep treating a condition, that isn’t resolving, over and over are either ignorant or completely ignoring the fact that we REFER TO A HIGHER LEVEL OF CARE! Just like all those physicians do – all those board certified physicians that I used to work with!

            Another thing – MY PATIENTS ARE DOING JUST FINE. The public has voted my clinic as the #1 minor emergency clinic every single year we’ve been open. Recently one of the large hospital systems named me as a finalist in their Health Care Hero program. So, there are people – PHYSICIANS AND PATIENTS – who appreciate us for our efforts.

    • Mengles

      Especially when studies have shown that midlevels refer out to specialists MORE than primary care physicians do. That is if they believe in truly taking care of the patient at all, vs. an ego boost.

  • buzzkillerjsmith

    As a PCP, I agree that midlevels aren’t docs. But here’s the thing: Those in the driver’s seat in health care in this country do not care. If you are a med student thinking about going into PC, please think again.

    Some think that debating the merits of all this is useful. I don’t. The game is over and we have lost.

    • icecoldchickenwings

      ” If you are a med student thinking about going into PC, please think again.”

      Why go to med school, go 200k+ in debt to in the best case scenario do a job that everyone seems to think someone with lesser training can do just as well? Not even that but the worse case scenario (and more likely scenario) is that we move to a system where providers are paid based on outcome (read penalized for complexity) and then the doctors subsequently get stuck with only complicated patients while the simple diabetics, hypertension, hyperlipidemia patients are gobbled up by the equal standing free practices of NP’s and PA’s. (On some level I”m of the opinion that if the states want to grant them indepenent practicing rights, the insurance companies want to actuarialize their risk, and patients are happy to see an NP/PA then I’m actually ok with it. I do think the above and below will be some unintended consequences of that decision however).

      I used to work for a practice that ran a pilot program for the state regarding diabetes management. The Endocrinologists in the multi-specialty group had the worse A1c numbers of the entire practice. Was it because they were worse at managing diabetes, of course not. It’s because of the negative selection bias that all of the complicated/non-compliant patients got funneled to the specialists. Had pay for performance been in place during that study time the Endocrinologists would have got paid less to take care of more difficult patients. It doens’t take much to extrapolate similar results for say asthmatics or heart failure patients for pulmonologists or cardiologists.

      When you add that some states have some laws working through the legislature to equalize pay for services provided by NP’s and PA’s to that of physicians (Passed the Oregon house earlier this year) any medical student who has their pulse on current trends of American medicine really has to ask themselves why they are going into primary care. Personally I think this blog and articles like this one should be required reading prior to entering the match for primary care. It could be like the End User License Agreement when downloading software. Do you really know what you are getting into by agreeing to do this?.

      • buzzkillerjsmith

        Agree 100%.

      • ninguem

        Can’t wait for the med students to start telling faculty:

        “If I wanted to go into primary care, I’d have gone to nursing school.”

        After the student evaluations are in, of course…….

        • LastoftheZucchiniFlowers

          sadly, this ship has sailed.

  • http://twitter.com/SheuSusan Susan Sheu

    We waited several years and changed insurance to see our amazing Family Practice doctor in Los Angeles, who cares for all three of the adults in our family (2 middle aged, 1 senior). Prior to that, we were unable to find a quality Family Practice doctor or Internal Medicine specialist. Anyone who was taking new patients ended up being not a very good doctor (one family member’s diabetes was woefully neglected under several different docs). And anyone who had a great reputation had a full roster of patients and/or a several month wait for an ordinary checkup. We had the luxury of finding our great Family Practice doctor this because we can afford to purchase excellent insurance, albeit at a huge chunk of our monthly income. What makes our doctor special may or may not have to do with her MD — her observational skills, her bedside manner, her ability to see the big picture, her follow-up on important issues, her dedication to her job, and for the senior family member, it’s especially her patience and her focus on preventing illness, disability, and diminished quality of life. The Nurse Practitioners I’ve seen over the years in the pediatric practice we bring our children to are often more observant, better at interacting with patients, and interested in prevention that the Pediatricians. Since interest in (and funding for) Family Practice training is waning in medical schools, it’s clear that more Nurse Practitioners are the best way to make decent basic health care available to all kinds of people. -Susan Sheu, MPH

    • Suzi Q 38

      I agree. Thanks for your post.
      The NP’s serve a viable purpose.

    • Mengles

      “because we can afford to purchase excellent insurance, albeit at a huge chunk of our monthly income.” —- this is the reason that you got good care, plain and simple. You want quality? You have to pay for it.

      • http://twitter.com/SheuSusan Susan Sheu

        Yes, that’s right. While our premiums and our diligence might buy the services of a doctor with an orderly waiting room and who doesn’t check her cell phone during a patient’s appointment, I don’t think that should make it impossible for people who have less to have decent health care.

        • ninguem

          Can’t say I know your exact situation, but you can usually see a doctor “out-of-network”. You pay cash. You say the doc didn’t take your insurance. You pay the doc cash, you get reimbursed by the insurance on their “out-of-network” fee schedule. It will at least offset what you paid out-of-pocket.

          Sometimes it works, not always.

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

      I don’t get it – why would anyone vote this comment a thumbs down?

  • icecoldchickenwings

    I will weigh in here as a private practice specialist and then let the mud slinging come my way. I have started to dabble in being a mentor/training practice for a regional PA school. As part of that process over the last several months I have assembled a cohort of cases from my office as they have come in that include interesting teaching points. This was a prospective list of cases when I decided to do this and as such they are cases that have presented in my office over the last six months. I’m an Endocrinologist by training so a lot of the cases I have assembled are teaching points in terms of interpreting tests,ruling out uncommon conditions, or the actual presentation of patients that are outside the norm in order to demonstrate red flags in evaluating relatively common conditions. Very few of the cases include MEN syndromes, thyroid cancer, or very advanced management topics at this point in time. Some of the cases are:

    1.) ? Conn’s syndrome in a middle aged patient with HTN, hypokalemia, on only a thiazide diuretic and calcium channel blocker, and a strong family history of hypertension.

    2.) Hyperparathyroidism in a patient with a minimally elevated calcium level, low Vitamin D, and normal PTH on a thiazide diuretic.

    3.) Does this 27 year old lady with an elevated total T4 and a normal TSH who just started on OCP’s a few months prior to testing have hyperthyroidism?

    4.) Type II diabetes uncontrolled with CKD, a serum creatinine of 2.6 on Metformin monotherapy and an A1c of > 10 for the last year.

    5.) “Worsening osteoporosis” over 2 years time (T score from -1.7 to -2.5) with no risk factors for osteoporosis and normal biochemical work up.

    6.) A 24 year old man with hypogonadism, headaches, and vision changes whose symptoms have “failed to improve on testosterone.”

    They all have one thing in common. The referring provider missed a key point in the history or presentation of the patient that either completey changed the diagnosis or the management of the patient. I understand that primary care providers don’t have the time to focus on one specific thing when caring for the whole patient, but I also note that every single one of the above cases was referred by a non-MD primary care provider or a non-primary care provider physician. When the going gets tough there is no substitution for a well trained physician primary care diagnostician.

    1.) hypokalmeia from HCTZ resolves with discontinuation of thiazide diuretic.

    2.) Vitamin D deficiciency and hypercalcemia exacerbated by thiazide diuretic.

    3.) Change in thyroid function studies because of estrogen mediated changes (from the OCP) in the metabolism of thyroid hormone (Total T4 = bound T4 plus Free T4, only Free T4 is active and estrogen increases the amount of bound T4). The patient’s free T4 and TSH are normal. The patient is euthyroid.

    4.) Metformin is contraindicated in patient’s with renal function compromised to this degree secondary to the risk of lactic acidosis a potentially life threatening complication (among other issues).

    5.) Nobody looked at the DEXA images and the patient’s spine was not positioned properly nor was it centered and the “osteoporosis” is from a poorly performed imaging study. The patient has a normal BMD. This case was actually a second opinion requested by the patient after another Endocrinologist had recommended treatment.

    6.) The patient has a macroprolactinoma with compromised vision and has hypogonadism as a result of hyperprolactinemia.

    • Suzi Q 38

      You make some valid points. I would not stay with my NP when my medical needs got more complicated.
      On the other hand, there are physicians that “miss” the diagnosis entirely, or miss key components of the illness that would have led to a much faster discovery of any given condition too.
      I have experienced this firsthand with my neurologist and gyn/oncologist.
      When my MS Neurologist and two neurosurgeons found out what I had been through, they were not happy.
      Sometimes, as a patient, you feel “safe” being cared for at a major cancer teaching hospital, but if your doctors are too busy or just don’t care, you are out of luck.
      I would take a more interested and concerned NP for my simpler medical needs any day. Especially one that did not rush me and actually listened to me.
      If you get a doctor that knows it all and won’t listen, then h/she is not worth the money your insurance company pays h/her.

      • icecoldchickenwings

        I do not wish to give the impression that I am demeaning or not giving credit to NP’s and PA’s for the good work that they do. I also think with the coming worsening physician shortage that their role is going to become even more important. I do think however that moving towards a pay for performance model, while simultaneously allowing NP’s and PA’s to practice independent of doctors is ripe with the possiblity for the NP’s and PA’s to care for the less complicated patients and then primary care physicians having to see only the more complicated patients.

        Under a pay for performance model the Docs may find themselves in a position where they are getting paid less to take care of more complicated patients all the while having higher education and malpractice costs. While across the street an independent PA/NP clinic spends the extra time listening to patients, getting better satisfaction scores, and having better outcomes in part because the patients they are seeing are less complicated.

        As I eluded to elsewhere on this thread. If states wish to allow nurse practitioners and PA’s to practice independently, insurance companies are willing to actuarialize their malpractice risk, and patient’s are happy to see them then on some level I think it’s fine. However, as soon as it becomes a performance based reimbursement model, providers will scrap to get the healthy patients and the NP clinics will use the absence of MD credentialing to push off the hard cases to the MD’s. In a similar way practicing specialists have more complicated patient’s in total than the referring primary care providers, at least for the given referred condition. A microcosm of this was found in the state pilot program I referred to elsewhere in this thread where during the study period the Endocrinolgists in a multi-specialty group had the worst HgbA1c levels of all the physicians during the study.

        • Suzi Q 38

          Thank you doctor, for your reply. I understand what you are saying. I have to go to work so I will reply later.

        • buzzkillerjsmith

          Excellent posts, doc. As a PCP and a preceptor for Univ of WA med students, I would add that pushing off the hard cases to MDs, the apparent business plan, neglects that fact that many med students are well aware of this plan. And unlike some other factors of production, they have consciousness and even free agency. Being a team leader for such a team is mortifying to a lot of them. What if CorpMed and our PC medical societies designed a new medical specialty and no one came?
          I expect the PCP shortage to worse, perhaps after a false dawn in the near future. Expect more such consults and even being backdoored into doing a lot of PC yourself. In case you haven’t already noticed.

          • icecoldchickenwings

            I left that multi-specialty group in part because after the other Endocrinologist left I was the only Endocrinologist left in a two county area. The beancounters that bought the practice wanted me to start doing primary care and unrecommended testing such as cardiac stress tests (for which I have no training) on asymptomatic diabetic patients in addition to covering a 200 bed regional referral center. Corp med is evil. So I said Buh-bye.

          • buzzkillerjsmith

            Beautiful. If, as a trained endocrinologist, you’re a little rusty on moles, colds, and sore tail holes I’d be happy to get you up to speed.

          • icecoldchickenwings

            very rusty. 10 years out, never looked back. sorry for the trained Endocrinologist formality. I sometimes go a little overboard with my descriptive writing flourishes :)

          • Mengles

            Nothing to be apologetic about. It puts very much what you say in context.

          • Suzi Q 38

            Good for you.

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

            Please move to South TX – I have a nice extra office and some exam rooms you can use for a very low cost. I would love to have an endocrinologist on site. There are lots of uncontrolled diabetics in our area and it takes forever to get in to see an endocrinologist. You would get lots of referrals and would be completely in charge of your practice. it would be a “win win” situation for everyone concerned!

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

            Now, why would that post get a thumbs down?

          • icecoldchickenwings

            While I didn’t give you thumbs down on the above post, or the one where I could interpret your response to telling me I have no life, I will say that if you represent a medical practice that wants an Endocrinologist leading any advertisement/conversation with all of your uncontrolled diabetics and the lack of representation by the speciality is not likely to yield you any good results.

            Without in house ultrasound capability, nuclear medicine, DEXA (the first three done by radiology does not count), preferrably on site lab, and some protection from your local hospitals you are unlikely to get any responses. There are only 5,000 of us in the country. While we don’t have much of a voice in the Game of Thrones that medicine has become our small numbers, niche role, and demand is about the only thing that keeps independent Endo’s a viable practice model.

          • ProudOkie

            Spot on. Refer everything upline to the team leader.

          • Mengles

            Yes, bc God knows you would have to.

          • ProudOkie

            Not that I would have to Mengles…..I just would. Because you hold the ultimate responsibility. And you are the leader sir or ma’am. Now where is my check and it’s 5:00. See you in the morning. Don’t stay too late.

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

            ProudOkie – don’t worry, there are thousands of docs who value us. Before I opened my clinic I worked side by side with several physicians. They thanked me for my hard work on almost a daily basis. They’re the silent majority. They’re far too busy taking care of complicated illnesses to waste their time reading KevinMD, much less posting comments that devalue the very people who make their life easier. It’s even more telling that these derogatory comments are made by anonymous posters. I wonder why they’re such cowards?

          • ninguem

            Well, I’d consider such a “team leader” position…….

            IF I were being paid accordingly.

            IF I truly had authority over the NP’s and PA’s, including hiring and firing.

            But what you usually get of course, is responsibility without authority.

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

            According to the Texas Medical Board’s rules, physician are only held accountable for their PA/NPs mistakes if they were directly involved in the decision that lead to the poor outcome OR they were aware the PA/NP was incompetent. HUH? As if a physician is going to say, “I knew that NP was incompetent the minute I hired her!” Talk about having your cake and eating it too! HA!

            BTW, you’ll never be “paid accordingly.” Do you really believe reimbursements will increase simply b/c you’re the team leader? It’s amazing to me how little physicians/PAs/NPs know about running a business. Until you’re a business owner you’ll never truly understand things like overhead, falling reimbursements, time management…

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

          icecoldchickenwings: As a NP who has witnessed just about everything, please let me share some of the cases involving board certified physicians:

          1) Physician prescribes phentermine to patient – she takes it daily for EIGHT YEARS. He also prescribes testosterone, estradiol, etc to patients who’ve never been screened for prostate or breast cancer. This involved THOUSANDS of patients.

          2. Board certified doc prescribes Tussionex to patient for insomnia..refills monthly for nine months.

          2) Patient was hit by a stingray – board certified doc prescribed Amoxil and advised pt to come back for tetanus. Pt returned every day for 3 days, still no tetanus. A week later, pt developed infection and went back for f/u. Doc said she was lucky it wasn’t a lot worse. No culture, still no tetanus, no prescription, no x-ray. Patient hospitalized with osteomyelitis a few days later.

          3) Patient with chronic epigastric pain and board certified PCP chalks it up to GERD – takes Nexium daily – no labs in 2 years, but still gets refills approved – no workup on abdominal pain. Ultrasound reveals almost complete occlusion of common bile duct – even had gallstones embedded in the liver. ALT/AST were well >1,000.

          4) Patient presents with fever, body rash, headache, reports recent tick and flea bites. Prescribed doxy and labs drawn that included Rickettsia panel. Symptoms improve within hours. Advised to see board certified PCP for f/u – info faxed to PCP. PCP discontinues doxy and prescribes Medrol Dose Pack, symptoms suddenly worsen, so PCP refers to allergist who wants to do allergy testing. IgM and IgG positive for RMSF.

          Now for some really good ones…

          5) Board certified pain management doctor has someone call elderly patients at home and advises them to come see Dr X ASAP. Unsuspecting elderly patients come in for visit to find it’s a “pre-op” visit for a procedure they know nothing about.

          6) Dr. X tells patients that if they want to continue to get scripts for narcotics, then they’ll need to let him perform some procedures on them…Whatever you say doc!

          7) Hospital physicians are caught overdosing patients on narcotics, so they’ll need to be intubated, therefore, increasing reimbursements. Some of the patients die. I believe that one was on the news recently.

          I could easily sit here and type up hundreds of scenarios involving STUPID MISTAKES and UNETHICAL S*** involving physicians, but I have a life.

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

      icecoldchickenwings: As a NP who has witnessed just about everything, please let me share some of the following cases involving board certified physicians:

      1.) Physician prescribes phentermine to patient – she takes it daily for EIGHT YEARS. He also prescribes testosterone, estradiol, etc to patients who’ve never been screened for prostate or breast cancer. This involved THOUSANDS of patients.

      2.) Physician prescribes Tussionex to patient for insomnia..refills monthly for nine months.

      3.) Patient was hit by a stingray – physician prescribed Amoxil and advised pt to come back for tetanus. Pt returned every day for 3 days, still no tetanus. A week later, pt developed infection and went back for f/u. Doc said she was lucky it wasn’t a lot worse. No culture, still no tetanus, no prescription, no x-ray. Patient hospitalized with osteomyelitis a few days later.

      4.) Patient with chronic epigastric pain and physician chalks it up to GERD – takes Nexium daily – no labs in 2 years, but still gets refills approved – no workup on abdominal pain. Ultrasound reveals almost complete occlusion of common bile duct – even had gallstones embedded in the liver. ALT/AST were well >1,000.

      5.) Patient presents with fever, body rash, headache, reports recent tick and flea bites. Prescribed doxy and labs drawn that included Rickettsia panel. Symptoms improve within hours. Advised to see physician for f/u – info faxed to PCP. PCP discontinues doxy and prescribes Medrol Dose Pack, symptoms suddenly worsen, so PCP refers to allergist who wants to do allergy testing. IgM and IgG positive for RMSF.

      6.) Board certified pain management doctor has someone call elderly patients at home and advises them to come see Dr X ASAP. Unsuspecting elderly patients come in for visit to find it’s a “pre-op” visit for a procedure they know nothing about.

      7.) Dr. X tells patients that if they want to continue to get scripts for narcotics, then they’ll need to let him perform some procedures on them…Whatever you say doc!

      8.) Hospitalists are caught overdosing patients on narcotics, so they’ll need to be intubated, therefore, increasing reimbursements. Some of the patients die. I believe that one was on the news recently.

      I could easily sit here and type up hundreds of scenarios involving STUPID MISTAKES and UNETHICAL S*** involving physicians, but I have a life

  • sarah93

    “We learn about where our patients live, what they eat, who they talk to, how they get around.”
    Sadly, this is no longer true. You may think it is, but in the day of the 15-minute visit my doctor knows absolutely nothing about my life. We barely have time to discuss my medical issues. She doesn’t know if I work, how much, where or at what. She doesn’t know if I’m still married, under financial stress or doing swimmingly materially speaking. There isn’t time to think about these “peripheral” factors any more.

    Oddly, the government and insurance industry still have doctors sign off on these things. I guess they haven’t noticed.

    • Mengles

      She works in academia, Sarah, so unlike in the real world, where 15 min. appts are the norm, she can see less patients at greater intervals due to her “teaching” obligations, and lecture the rest of us as to why we can’t do it like she does.

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

        Hey Mengles – I don’t think Sarah93 was referring to the author.

        • Mengles

          Hey Cyndee, she quoted the author: “We learn about where our patients live, what they eat, who they talk to, how they get around.” My point is that unlike Dr. Reisman, most doctors in the trenches don’t get the liberties that she does working in academia.

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

            Mengles, well neither do NPs! I’m lucky if I finish my charting for the day – not much time for socializing!

  • Suzi Q 38

    Thank you for your article and your good, positive attitude.

  • Mike

    Good catch with that stat. I’ve bookmarked the link!

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

    Why doesnt Anna Reisman resign from her position at Yale so that an NP can take over? Why are we paying her such a high income when an NP can do the same job for less?

    • Mengles

      According to the Yale website, she doesn’t accept any new patients, so that very well may be the case. There are benefits to working in the Ivory Tower.

    • ninguem

      She’s at Yale. They accepted a spokesman for the Taliban a few years ago.

      She’s fitting right in with a Yale worldview.

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

    Obamacare mandates that NPs and PAs get paid the same as physicians (except for Medicare).

    Why would I pay the same to see a nurse when I can see a real doctor instead?

    • civisisus

      “Obamacare mandates that NPs and PAs get paid the same as physicians ”

      citation? I’ve seen no reference to this heretofore

    • Suzi Q 38

      That is what is going to happen. The patients will decide, depending on your availability or access to them.

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

      I wish that were true! My insurance contracts reimburse me less than Medicare does! SHOW ME THE MONEY!

  • Jennifer :D

    *Vigorously applauding at the monitor*

    • Guest

      ::envisions a seal clapping::

      • out of here

        Trained seal. Does what it’s told.

  • Guest

    Whatever you do, don’t Google “nurses+bondage”. Not if you don’t want to set off alarms in IT & HR. ;-)

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

      LOL – I had to see what I would find, so I Googled “nurses+bondage” and then clicked on “images.” O.M.G. I didn’t need those visuals! Trust me, you don’t want to go there…or maybe you do?

  • Mengles

    Only to Dr. Reisman, is corporatized bondage with Walgreens perfectly ok.

  • Elvish

    “As of early April, you can walk into Walgreens in 18 states (plus D.C.), and along with a gallon of skim milk, a pair of photo mugs, a six-pack of toilet paper, and a flu shot, you can meet your new primary care provider, get your cholesterol checked, pick up your statin, and schedule a return visit. ”
    I just can not believe a doctor would accept the above scenario !
    Personally, every time I walk into one of those stores I criticize them for selling tobacco, alcohol and the rest of their garbage next to medicine, and now this “fellow doctor” is promoting this scam and scandal to be.

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

    Thanks for the laugh!

  • ninguem

    “…..As of early April, you can walk into Walgreens in 18 states (plus D.C.), and along with a gallon of skim milk, a pair of photo mugs, a six-pack of toilet paper, and a flu shot, you can meet your new primary care provider, get your cholesterol checked, pick up your statin, and schedule a return visit……”

    Anna Riesman…….You forgot “pick up beer, wine, liquor depending on the state, candy, potato chips, junk food, and tobacco”.

    All but the most marginal of physicians would be ashamed to work in a setting like that. If that were my only choice, I think I’d leave medicine.

    That nurse is freed from bondage? That’s the dumbest thing I’ve ever heard. A nurse working at Walgreen’s is in even worse bondage. She’s now nothing but a shill for Walgreen’s corporate.

    I steer my patients AWAY from Walgreens They got nailed for aiding and abetting the pill mills in Florida. Now they ask the most intrusive questions of my narcotic patients, claiming “it’s the law”…..which is….I gotta call it what it is…..a lie, I checked the rules directly with the State Pharmacy Board and regional DEA.

    Just this past month, I got a preauthorization request for terbinafine. Why, it’s four dollars. Turned out my local Walgreen charged $60.

    I told the pharmacist to return the prescription to my patient and instruct my patient to fill elsewhere……or fill it for Wal-Mart and Rite-Aid’s price (everybody else’s price) of four dollars.

    I had a patient on Suboxone, he tried to fill at Walgreens. The pharmacy presented me with a long questionnaire about my patient’s addiction history. Claimed “it’s the law”, and both the pharmacy board and local DEA said otherwise.

    “Give the prescription back to my patient and tell him to fill elsewhere”.

    Now tell me. If I were a nurse practitioner, working in a Walgreens, and I advocated for my patients against a pharmacy that was ripping off my patients, how long do you thing I’d last there?

    I’d be yelling at my patients across the store “don’t you dare let me catch you at the tobacco counter”.

    Yeah, I can see it.

    I’m not even going to bother to bring lunch, I won’t last that long.

    • Mike

      What he said.

    • Mike

      If you’re going to become a Walgreens shill-for-profit, you also have to come to terms with the idea that any of your prescribing data or any of your patients’ personal medical data may well end up for sale to the highest bidder.

      (Reuters Legal) -
      “A lawsuit filed in California this week accuses national drug-store chain Walgreen Co of unlawfully selling medical information gleaned from patient prescriptions, another front in the battle over personal information.

      “According to the suit, brought by Todd Murphy on behalf of his two daughters and the rest of the class, Walgreen sells the prescription information to data mining companies who resell it to pharmaceutical companies for marketing purposes.

      “The practice allows drugmakers to target physicians considered high-volume prescribers and those most willing to prescribe new medications, it said.”

      There is more in the Mother Jones article, “Is Your Drugstore Selling Your Private Information to Big Pharma?”

      I cannot fathom why any doctor with the best interests of their patients at heart would sell out to Walgreens or CVS type models.

      • ninguem

        Oh, yeah, that’s right, thanks Mike.

        Do an experiment.

        Write a prescription for prenatal vitamins for your dog.

        Fill it at your local pharmacy. Pay cash.

        See how long it takes for Fido to get mailings for baby furniture and disposable diapers.

        I can’t blame that on just Walgreen’s, they all do it.

        But that’s what the nurse-practitioners have been “liberated” to do, shill for Walgreen’s.

        So imagine a physician office where you sell cigarettes and liquor and junk food……AND you sell patient data to marketers.

        • Elvish

          Is this an ethical or a cultural problem ?

          Did Right and Wrong switched places or we simply stopped caring for the sake of profit or convenience ?

          Medicine is a sacred profession and we, in the U.S., are demonizing it with our greed and laziness.

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

          If physicians (not all, but most) were able to sell their patient’s information to make an extra buck, you better BELIEVE they would do it.

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

        This has been going on for years – with ALL the big pharmacies. People are just now realizing this?

        BTW – physicians sold out their profession years ago when they started letting NPs/PAs treat their patients. People soon realized they received the same or better care from the NPs. Now those same NPs are opening competing practices and the physicians are up in arms!

        If physicians are worried about losing patients to the NP at their local Walgreens, then maybe they should look in the mirror and figure out why that’s the case.

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

    Ooooh honey! Into the breach with you! Bold statements, I’m sure you’ve seen by now the vitriol from the physician community this subject always evokes. I have said much the same. Let’s work together

    • Guest

      “Into the breach with you”

      What does that even mean? If you were (mis)quoting Shakespeare (Henry V) “unto the breach”, it doesn’t mean what you apparently think it means. If you really did mean “into the breach”, as in “step into the breach”, it still doesn’t make sense in your context.

      It’s okay if you’re culturally illiterate, but you shouldn’t be so proud of it.

      • http://www.facebook.com/preston.gorman.9 Preston Gorman

        Wow, way to attack the person instead of the message! I’m sure that you are very proud. Arrogant much?

  • http://www.facebook.com/patricia.dyer.31 Patricia Dyer

    I am a pediatric nurse practitioner. I do not need to be told when to ask for more expertise – and almost without exception – that expertise has been from a physician expert (other than my collaborator) or another NP or a pharmacist. In New York, the collaborator has to review 5% of my records every 3 months. A ridiculous requirement that does not improve my care at all.

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

      Oh yeah – a RETROSPECTIVE chart review does SO MUCH to ensure safety!

  • Julz777

    I am a FNP with 6 years of experience in family medicine. I currently work in a hospital based residency program clinic setting. This is a disproportionate share hospital with high acuity patients. I see all of the same patients the residents do. All of these patients are very complex with multiple comorbidities. I thought I was a pretty good clinician prior to starting this job but I can say I am now 10 times the clinician I was prior to this position. I feel very prepared to handle the majority of situations which arise with these very difficult and complex patients. I still consult with my collaborator when needed and she regularly reviews my charts and is almost 100% of the time in agreement with my plan of care. I think every NP should work in this type of environment when feasible and if they can prove themselves competent after caring for not only acute but the chronic high acuity outpatients then at some point the NP should be released from the requirement of a collaborative agreement. I appreciate the ability to collaborate with a physician to improve the care for my patients when needed but I don’t think an NP should be denied the right to practice independently what they have proven themselves to be a competent clinician over time. If my collaborator quit today I would not be able to practice until I completed another 30 days with another collaborator. That is not what is best for patients who have such limited access to care already.

    • Guest

      If you wanted to be a real doctor, why didn’t you go to med school?

      • Julz777

        I wanted to be a nurse. Who said I wanted to be a doctor? Being a nurse is a pretty cool thing! I have been a nurse since I was 21 years old and I wanted to advance in my career so I went back to school to be a NP. I have excellent patient outcomes and my patient satisfaction scores are in the 90th%. What’s wrong with that? Why would I start over from ground zero to go to med school? That would be foolish. I am improving lives and making a difference as a NP. That’s what it is all about. Why is it everbody thinks you have to be a “doctor” to be a good clinician? Get over yourself guest…. What a cliche’ statement.

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

          Please respect the fact that there are people out there like Guest that would rather get the care they need from a physician. The reason why everyone thinks you have to be a good physician to be a good clinician is for the safety of the patient, and the community in general as a whole. I know some of the other NPs on here don’t agree with me, or others that feel like me and that’s fine. However, when those good outcomes that you talk about start to lower because of the bad outcomes which then lead to the lawsuits and other problems that come with that responsibility people will realize that we need physicians. Problem is that by the time that realization occurs it may be too late for everyone. What then?

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

            Kristy – are you completely oblivious to the fact that we’ve been around for over 40 years? We’ve had COMPLETE INDEPENDENCE in my home state of New Mexico for over TWENTY YEARS. This isn’t a new phenomenon – do you not understand that there is a lot of data that supports the fact that patient outcomes are the SAME if not BETTER when patients are treated by a NP? We’re NOT trying to replace physicians. G-d knows, there are times when I have to refer patients to an internist or some other specialist, but I can handle the majority of situations that present in my clinic every day.

    • Guest

      “I don’t think an NP should be denied the right to practice independently what they have proven themselves to be a competent clinician over time.”

      I agree with this. Otherwise, NPs should be willing to sit for the same standardized exams that physicians do if they want to practice independently.

      One problem I have is that when I meet a pediatrician, for example, I know exactly what their education and training is. When I meet an NP I might be dealing with someone who worked in the military or ICU for years prior to getting their NP degree. Or, I might be dealing with an NP who had no clinical background prior to getting their NP. I wish there was a way to standardize.

  • http://twitter.com/NPcouncilMiami NP Council Miami

    And the comments from bitter physicians begin…realize you caused this by over specializing and abandoning primary care…move over, it’s our turf now

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

      You are exactly right! What “they” can’t seem to fathom is that it’s THEIR fault. This started when anesthesiologist got lazy and began having CRNAs do all the work. Of course, the anesthesiologist got a “cut” out of the reimbursements, so they were more than happy to keep “supervising” more and more CRNAs. Yeah…SUPERVISING…half the time they weren’t even in the same hospital.

      Fast forward a few years and the people in charge (who are NOT physicians, but businessmen) started to notice that patient outcomes were the same as the physicians. They wondered why they were paying twice as much for a physician as a CRNA when the patient outcomes were exactly the same. Granted, there were those special cases, such as heart transplants where the physician was needed, since they were trained to handle the more complex cases. But the vast majority (around 90%) of those cases weren’t complex cases, but cases that could easily be handled by a CRNA.

  • DrJKH

    What a bunch of nonsense liberal pap. Dumbing healthcare down even further than Oblamercare already does is NOT a solution. Nurses should go back to being nurses and leave medicine to doctors. If a nurse wants to be a doctor, there is an outlet for that: Medical school!

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

      DrJKH – THERE AREN’T ENOUGH PHYSICIANS!

      • DrJKH

        So we dumb down the quality of care and let unqualified people practice? Nope. There are solutions that could be done, but dumbing down care shouldn’t be one of them.

        • Guest

          Correct. That’s exactly what we do. Administrators and bean counters much maintain profit now that volume will be increasing thanks to ACA.

          Profit = revenue (low payors like medicaid) – expenses (lower price of care using midlevels).

          Sounds peachy, doesn’t it?

  • njfamilydoc

    I guess with all else that is going on with healthcare in this country… sure, Why not?
    The only thing I would want is that the NPs should be allowed to sit for USMLE step 2 and 3; same board certification exams and carry the same liability as doctors, same insurance premiums and be held to the same level of competence as doctors in case of a lawsuit. THEN, you are more than welcome. We don’t mind sharing this HELLthcare “turf”…

  • Cyndee Malowitz

    Nevada nurse practitioners just gained full independence last week. California isn’t far behind…independent practice bill passed the Appropriations Committee and continues to have strong support. And you guys are still quibbling about this! That ship has already sailed!