Why I rely on non-physician providers

Why I rely on non physician providersI still recall my first rotation as an inpatient attending at Memorial Sloan-Kettering Cancer Center (MSKCC). Perhaps it was the anxiety that I remembered most; that I was “in charge” of a service. Fortunately, having done fellowship at MSKCC, the system was not a foreign one, and I knew exactly where to go to get oriented—I went to Jane and Dorothy, our nurse practitioners whose full-time job was to help care for the women on our inpatient gynecologic oncology medicine service.

During that time, I admitted “Linda.” She was young, married only recently, and had been urgently transferred to our hospital with a rare cancer—metastatic gestational trophoblastic disease. As her stay went on, I would visit her and her husband after rounds, and it became routine for me to stop by her room to chat with them both before I left for the day.

After four weeks as the inpatient rounder, I rotated off service. Swept up in outpatient responsibilities, I never did get back to the floor. Yet even while I was back in my “regular” job, I found myself wondering how Linda was doing. One afternoon, Jane paged me to the floor.

“Hey, Jane, what’s up?” I asked.

“Hi Don; just an FYI—Linda is doing great and will be going home today. She wanted me to make sure you knew.”

“That’s great,” I replied, smiling. “Please tell her and her husband I wish them well,” I said.

 “I already did,” she said.

Even today, I find it reassuring that Jane was able to close this loop (and many others) for me.

No matter how much time goes by, I always have a certain sense of anxiety when my turn as inpatient attending comes up. In my current role at Massachusetts General Hospital (MGH), I am only required to do this for a few weeks a year; however, it is still daunting to care for patients admitted with little knowledge of “who” is in house, let alone “why.” Fortunately, like MSKCC, MGH has a group of exceptional nurse practitioners to help us take care of patients on the inpatient service.

In my career thus far, I consider myself fortunate to have worked with non-physician providers who, like Jane and Dorothy, have participated in the care of my own patients. In the inpatient setting, it meant helping me to get acclimated to the service, patients, and their loved ones. More than that, I have also come to rely on them as a way to ensure my patients (both inpatient and in clinic) get the highest level of care we are capable of providing.

Ultimately, despite the demands on time, duties of outpatient practice, and objectives to be met in academics and beyond, physicians have an obligation to meet the needs of their patients. That job is easier thanks to the men and women who, like us, have devoted their own professional career to the care of patients with cancer. Working in partnership, we can achieve most of what all of us aim to accomplish, without sacrificing the quality care that our patients deserve. It is a model of health care delivery I have learned not only to embrace, but to rely upon.

Don S. Dizon is an oncologist who blogs at ASCO Connection, where this post originally appeared.

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  • Dr. Drake Ramoray

    Summary: You like nurse practitioners because they take care of patients for you while you do other things your institution deems more important and the only concrete example you provide is that one called you to let you know one of your patient’s was going home and provided your best wishes for you? Were you up against some deadline or something for this piece?

    People in the ivory towers wonder why we think they are out of touch? I’m new to this site but I’ve yet to see a piece from one of the academic types that’s been well articulated, added a thoughtful point, or contribued to the practice of medicine in a meaningful way.
    I like the guy who cuts my grass. He always does what he says he will do. His quotes are accurate and his bills are timely. He provides reasonable recommendations for yard maintenance. Sometimes he goes the extra step and does things like bring my garbage can up from the street. His name is Nick. Everyone now knows more about my lawn guy and how good he is at his job than they do about your nurse practitioners and it only took me one paragraph to write about it.

    If I was a nurse practitioner I think I might be offended by this piece.

    • Guest

      .

    • Cyndee Malowitz

      Dr. Ramoray a.k.a. icecoldchickenwings – you mentioned in an earlier post that you were retired, so which is it? I’m beginning to wonder if you’re even an endocrinologist, as you’ve mentioned before. If you’re truly a physician, how is it that you have time to post comments on KevinMD ?

      So, either you’re lying about being a physician OR you have a NP/PA doing all your work while you post comments on this site.

      Just curious.

      • Dr. Drake Ramoray

        Yup work 24/7 365. No lunch, no vacation, no time off evar! Clearly either I’m lying or I have to have an NP/PA seeing all of my patients. How on earth could an office survive without one.

        In retrospect I could have been less agressive about it, but I think this piece is a discredit to the work that NP’s/PA’s do and is primarily an example of the bubble that doctors live in, and your response is to pick a fight?

        • Cyndee Malowitz

          Wow – that was a quick response! I have a NP working for me too, otherwise I wouldn’t get a break either, considering my clinic is open 7 days a week.

        • Mengles

          It’s what she’s best at doing. Well that and making the news by filing lawsuits and complaining to medical boards about doctors she doesn’t like.

          • Cyndee Malowitz

            Hey Mengles – you have absolutely NO CLUE what you’re talking about. Don’t be so foolish! If you have any questions, why don’t you PM me on FB? Of course, then your identity will be revealed and I’ll discover you’re not even a physician, but someone who flunked out of CRNA school.

            Both you and Dr. Ramoray have way too much time on your hands. There is NO WAY you guys are practicing physicians. If you are, then you aren’t successful ones or you have a NP/PA doing all your work.

          • Jason Simpson

            How is Dr David Gray doing? I’ll make sure to call up the office and let him know that you think you’re a better provider than he is. LMAO

          • Cyndee Malowitz

            Jason Simpson – stalk much? Considering the fact that he’s my mentor I would LOVE to listen in on that call. That is, if he even bothered to take your stupid phone call, considering he’s a “REAL” doctor and he’s saving lives!

        • Cyndee Malowitz

          I don’t know what you’re talking about. Are you responding to something I wrote? It looks like Kevin Pho deleted another one of my comments.

          I noticed that my comments have to be approved by a moderator now. I wonder why my comments are censored and not Mengles or Dr. Ramoray’s? I thought this site was open to everyone. Why is it that physicians get to slam NPs, but my responses get deleted?

          • Dr. Jess

            Just FYI, I highly doubt Kevin Pho himself is deleting your Disqus comments. Disqus, the commenting platform used by a wide range of blogs, has an option for readers to “flag” comments they find inappropriate or otherwise objectionable, and after a certain number of reports the comment gets deleted.

      • Mengles

        One could ask how you have time to post comments on KevinMD as well.

        • Cyndee Malowitz

          I have a part-time NP working for me, that’s how!

    • Mengles

      “Hi Don; just an FYI—Linda is doing great and will be going home today. She wanted me to make sure you knew.”

      “That’s great,” I replied, smiling. “Please tell her and her husband I wish them well,” I said. “I already did,” she said. Even today, I find it reassuring that Jane was able to close this loop (and many others) for me.
      =================
      If this had happened to me, I would be utterly ashamed of myself for delegating “closing the loop” to someone else. What’s worse, is that this author is patting himself on the back for it.

    • drdondizon

      Dear Dr. Ramoway,
      Yes- I wrote about my impressions, my thoughts, and my experiences- and this piece reflects only my opinions. I am sorry if you were expecting a treatise on the role of nurse practitioners in oncology practice. Perhaps next time?
      But I think you’re major point might be correct- that the experiences of those of us who practice in an academic institution is incredibly different from the one of a clinician in private practice. However, it does not make it any less relevant.
      I am unsure why you feel it was insulting to NPs or PAs; if anything I had hoped to illustrate how important they are and have been to making sure clinical care is not negatively impacted by the roles each of us play- as clinicians, administrators, and/or academics. Medicine is a collaboration- has been ever since I started practice as an attending.

      If anything- I had hoped to highlight the importance of others in making that collaboration work.

      DSD

      • Dr. Drake Ramoray

        DSD,
        “I am sorry if you were expecting a treatise on the role of nurse practitioners in oncology practice. Perhaps next time?”

        I enjoy your sarcastic sense of humor. I posted the biting commentary I did because your entire piece is completely oblivious to the current dialogue of nurse practitioners practicing independently of physicians. Your doing your 3-4 weeks of inpatient rotations, completely oblivious to the pending change in the landscape of medicine. Not only do you convey the role of nurse practitioners without seeing how it is looking that it may evolve, but even in their supervised role you provide nothing in your piece to support the quality care that they are already performing. If nothing else, you give the impression that they are off running the inpatient wards and you have little clue, knowledge, or comfort with what is going on.

        I’m more open to nurse practitioners practicing independently than a lot of docs on these boards. I think one serious thing that would have to be resolved is payment, but I’m actually more open to the idea than most. Your piece does not align with current trends in medicine and provides no meaningful information other than the kind of medicine you are able to practice in the academic setting. If I was a nurse practitioner I would hold up your article as a reason that I don’t need supervision and that you don’ t provide any concrete evidence of the good work that I do in my current role.

        • drdondizon

          Dear Dr. Ramoray:

          Perhaps if you would see the piece for what it is- and not what you think it was “supposed” to say (whether for or against an independent NP), it would be easier to accept it for what it is. I can only speak to my experience, and my gratefulness. If I came across a flip or nonchalance- I do apologize. But in my world, NPs and physicians work together. Period. And I am happy about that.

          I think if anything- all of us in medicine like to be acknowledged- it does not happen enough.

          So- in my piece I wanted to say thank you to those who work by my side.

          And so I did.

          DSD

          • Dr. Drake Ramoray

            Yes, you have thanked them, but you still don’t understand what is going on outside your tertiary medical center setting.

            I could thank Lois Lerner for treating my taxes correctly, but it probably wouldn’t be the best time to do that either.

          • drdondizon

            Dear Drake- hopefully we can be on a first-name basis as colleagues.
            My point was a simple one as well- acknowledge the work others do. It’s a simple message that has gotten mired in an ongoing turf war. Too bad really.
            Best to you though- DSD

          • Dr. Drake Ramoray

            A day doesn’t go by that I don’t thank my MA and the people I work with for everything. Hand me a chart and tell me the next patient is ready, Thank you. Tell me some drug rep needs my signature and I don’t really want to talk to them, Thank you. Thank you’s go a long way. Your point is very well taken, although it’s getting a little rough outside the academic centers (I’m sure you have your own challenges).

            Good evening to you as well.

          • drdondizon

            Point well taken. Best of luck out there. We have our share of issues in the ivory towers of America but I do hear about what is happening in communities. All we can do is push forward, work for change. I bet your staff appreciate the kudos. I am recognizing that it is something I haven’t often done enough. But I’m trying.
            Take care, Dr. Drake. DSD

          • Cyndee Malowitz

            Dear Dr. Dizon – Dr. Drake Ramoray is a character on a soap opera. Of course, you wouldn’t know that because you’re busy saving lives and don’t have time to watch daytime TV. I’m pretty sure “Dr. Ramoray” isn’t even a physician. He used to leave comments under the pseudonym “icecoldchickenwings,” and he’s always slamming NPs.

          • Dr. Drake Ramoray

            Yup. I state I’m open to nurse practitioners working independently on the national level if the payment part gets worked out. I point out that the author of this original piece didn’t really give any NPs credit for any actual work they do. You on the other hand have accused me of having no life and being a pompous jerk. You are so raving mad on here that you don’t see that we actuall agree on some things.

          • Cyndee Malowitz

            What do you mean about the “payment part?”

          • Dr. Drake Ramoray

            If healthcare was as simple as a free market I would be happy to let you set up shop across the street. Post your credentials, set your prices, and have at it. Let patients and the market decide what value there is for your services. If you make more money than me, more power to you.

            Healthcare is not a free market with prices essentially set by Medicare with private insurance for a large part following suit with some %rate of Medicare (for E & M codes at least).

            If NP’s make the same fee for service as MD’s then why would anyone go to medical school (takes longer, have no earning power during training, and costs more)? If NP’s can perform primary care duties (and many rightfully argue for the most part that you can) and get paid the same then why spend the extra money and time to get an MD? If NP’s can practice independently and make the same money as a physician, then why not set up NP fellowships for independent practice and eliminate medical school altogether. It’s only two extra years of training for many physician subspecialists and many subspeciatly programs for NP’s are only one year.

            If NP’s make the same money, and can practice independenty then why can NP’s be held to different competency standards for clinical hours and for board certification and the like (I realize you have certification requirements, and I wouldn’t wish the ABIM on anyone and this is actually one point that could be made independent of pay.)

            If you continue this process long enough you essentially eliminate MD’s (or at least MD’s as we know them) because there is no financial incentive to go to becoming a doctor over becoming a nurse practioner and the responsibilties will have become equal. (A case can certainly made that current medical school training is a dinosaur whose basic formula has not been changed much in the last century). If anything, less people would want to become doctors because you would only get stuck with the hard cases (one of the weaknesses of the physician led ACO model anyway actually).

            If NP’s are paid less fee for service (depending on how much) then the corporations and hospitals will gobble up NP’s like there is no tomorrow, reduce their overhead, charge facility fees and make a killing. (I believe current Medicare rates are 85%.) This will accelerate the end of the independent physician and probably the independent nurse practitioner as well. Hopefully we at least share that hospitals do not share the best interest of health care providers when dealing with patient care.
            This also raises the vexing question of how much less pay as your current pay on some level has to include that you aren’t independent (in many states). Practicing independently may also change your overhead in terms of malpractice costs. Pay much less for Medicare or Medicaid and you won’t be able to see large numbers of them when you are losing money caring for them as well.

            If we move to pay for performance and the pay is the same there is a ton of room for independent NP practices to game the system, collect healthy patients, and turf the hard cases to the physicians. (I predict physicians and hospitals will try and do this to other physicians as well (see: referrals to Endo for non-compliant diabetics)).

            I know plenty of excellent PA’s. The one where I did fellowship was very good, especially when it came to diabetes. I know many excellent NP’s (some of whom I would see over some of our local doctors). With the healthcare provider shortage in this country, especially with an aging population and theoretically more people with insurance I can see how this could be a method of expanding access to healthcare, I’m just not sure how reimbursement could be squared with the cost both financial and the impact on lifestyle of becoming a physician.

          • Mengles

            They don’t want to post their credentials. That’s why they fight laws being passed at state levels that say you have to identify who you are: MD, RN, etc. bc they pull crud like calling themselves Doctor with the patient not realizing that they are not physicians.

          • Mengles

            Amazing to me that you can’t even get that his username is from the tv show Friends played by Matt LeBlanc a.k.a. Joey. Something so basic even in his avatar, and you’re taking care of patients? Scary.

          • Cyndee Malowitz

            Mengles –

            Because recognizing the characters from a TV show I’ve never seen has so much to do with patient care. You’re an idiot.

          • Cyndee Malowitz

            Wow! Can we clone you? You have no idea how refreshing it is to have a physician show their appreciation for us! Actually, I know lots of physicians who appreciate us, but they’re busy saving lives and don’t have time to leave comments on kevinmd.com.

          • Guest

            Drake Ramoray is a moniker from Friends FYI.

            And your insults are pedestrian. Claiming people are losers for having all this time to post here when you are among them makes you look incredibly foolish!

            I wonder if you know that. FYI, I’m not a physician, so save yourself the keystrokes it will take to make that accusation.

          • Cyndee Malowitz

            The only time I can post comments is in the evening or when my NP is filling in for me. I’m at the beach today – lucky me – I’ll post all I want.

            BTW, I didn’t say they were losers, I said it was highly unlikely they were physicians. The physicians I know WORK during the day and they’ve never even heard of kevinmd.

          • drdondizon

            Dear Cyndee- I was trying to figure out which post to reply to you so you are aware that I have indeed followed this conversation.

            I bet there are many of us in specialty practice who see NPs and PAs as collaborators- whether in an academic or a community hospital.

            Because I have always worked with NPs and PAs professionally I have tremendous respect for their skills, passion, and comaraderie. Sometimes there is tension- but it’s not due to a “who’s better at doing this” types of situations; rather it’s about what’s “best” in the interests of the patient. I can think of many occasions where I was challenged about a recommendation by an NP, which ultimately made me rethink my plans.

            Medicine isn’t a profession best practiced in a silo. That much I have come to know and appreciate.

            Take care, DSD

          • Cyndee Malowitz

            Thank you Dr. Dizon! I happen to know there are a lot of physicians who value NPs. Some of my best friends are physicians and we all seem to get along just fine.

            It amazes me when I read some of these comments which are supposedly written by physicians. Of course, they never use their real names, so I highly doubt they are truly physicians. I’m pretty sure they’re written by people who flunked out of NP or CRNA school.

        • Cyndee Malowitz

          Guess what Dr. Ramoray: The Nevada Legislature just passed a bill allowing for FULL INDEPENDENCE for NPs last Friday. A similar bill just passed the California Senate late yesterday. They will join the many states where NPs ALREADY HAVE full independence, including my home state of NM, where we’ve had independence for over TWENTY YEARS. CHECK IT OFF!

          • Jason Simpson

            But you’ll always be a NURSE! I dont care how many crappy fake doctorate degrees you put behind your name!

          • Charlie Buscemi

            let me know what part of town you are in…I can refer you to a Psych NP. hang in there buddy, there is help for you.

          • Guest

            ALL CAPS and LOTS!!! of EXCLAMATION POINTS!!!!!! make you look really MATURE!! and PROFESSIONAL!!11!!!!

          • Jason Simpson

            LOL I’m glad you brought up New Mexico. The idiot governor said that giving NPs independence would mean all the rural New Mexico folks would get good primary care. He was wrong!

            In 1990 there were exactly 23 rural clinics in New Mexico run by MDs.

            In 2012 there were 24 rural clinics, and only one of them is run by an NP.

            NPs like 9-5 hours working in big cities just like doctors do. They also like working as employees, they dont like running their own business/clinic.

            Thats why for every “independent” NP running a clinic, there are 10,000 who work 9-5 jobs under a doctor.

            This is why NPs will never solve the primary care problem, even if they get full independence.

          • SBornfeld

            Will you be sending a delegation to the UN?

          • Mengles

            Funny how you can only get your “scope of practice” by lobbying and bullying state legislatures instead of asking patients.

          • Mengles

            Yes, New Mexico has had independent practice for nurses for TWENTY YEARS, and New Mexico STILL has a deficiency in primary care providers. Oops.

  • SiMBa37

    The dialogue today is not about NP’s looking after inpatients for a supervising attending physician. The dialogue today is about an NP entirely replacing a physician in all aspects of care without a supervisor above.

    Your story is heartwarming, but a bit irrelevant to the current debate.

    • drdondizon

      Dear SiMBa37,

      I actually never intended to get in to the current debate about NPs being independent versus working “under an attending”. I actually never considered NPs as working “under” anyone but rather always thought of them as part of a team. Perhaps it is naive, but this is also my own experience.

      Clinical care is fairly demanding on all of us, and one wants to ensure that despite whatever your professional demands are, patient care does not suffer. I have worked my entire career in academic medicine, which for me, entails writing, teaching, research, and clinic. I can only hope that my patients felt that I did (and do) take care of them as best as I can- and I am enough of a realist to understand that it would not be possible unless there was a culture of interdisciplinary collaboration. This has (fortunately) been the constant in the institutions I have practiced in.

      Whether NPs should be independent providers or not was beyond the scope of my piece- I certainly have worked alongside some who have been mentors and colleagues, and certainly could work without supervision. As important as that debate is (particularly with the shortage of physicians currently and only expected to get worse), it’s as important that the relationship between NPs, PAs, physicians, and nurses be one based on mutual respect and collegiality.
      I would hope on that we can agree.

      Thanks for posting, DSD

      • SBornfeld

        Thanks for clearing that up–for a moment I thought I’d entered the Twilight Zone…
        Incidentally, my family has unfortunately had plenty of contact with MSK. The nursing care overall has to be characterized as first-rate. The docs ain’t too shabby either.

        • drdondizon

          Dear SBornfeld: You are welcome. Yes- MSKCC is an amazing and terrifying place at the same time. Amazing because the expertise is unparallelled and the quality of care is exceptional. Yet- it is a cancer hospital and having had the honor of being an attending there- it is the look of fear in so many faces at their initial consultations that follows me, and motivates me to hopefully find better ways to treat gynecologic and breast cancers, if not to cure it. DSD

  • Charlie Buscemi

    nurse practitioners are NOT “non-physician” providers. Luckily under Obamacare NPs will have an expanded role and start owning more clinics. I think I’ll hire a “non-nurse” provider like an MD.

    • Jason Simpson

      Dude! You’re a male nurse! LMAO!

      I love all those fancy letters you put behind your name! I also love your “research” including case reports on wound healing! Thats some groundbreaking stuff!

      • Cyndee Malowitz

        Jason Simpson – you are a sexist PIG. Do you assume that all physicians are male and all nurses are female? Which planet are you from? I know LOTS of male nurses and LOTS of female physicians!

        • Charlie Buscemi

          Its ok Cyndee. I am proud of my degrees and my two board certifications. I’ve read some of “jason’s” posts and I actually feel sorry for him.

          • Jason Simpson

            Yeah your fake nurse certifications! Where did you get those, out of a cracker jack box? LOL

      • Dr. Jess

        How old are you, Jason? Twelve?

      • Kathleen Kettles

        Dude, you have now sunk even lower than I thought possible.

      • Mengles

        And in such high quality journals like the Journal of Cultural Diversity (no joke).

  • Jason Simpson

    Why are we paying you 200k a year when an NP can do the same job at less than half the cost?

    Why arent Jane and Dorothy deciding which chemotherapy people get? Why arent Jane and Doroth doing all of the initial evaluations on new patients who have cancer?

    In short, why do we need an oncologist like you at all when a nurse with 1/4th of the training can do your job?

    Dont you feel like you are stealing money from MGH?

    Dont you have an obligation to resign your position from MGH since you freely admit that you provide no more value than what a nurse provides and they can do it at a cheaper cost?

    • drdondizon

      Hi Jason,

      I am unclear how my post became an “us” versus “them” argument of NPs versus MDs- it certainly wasn’t what I intended. I am happy to have worked with wonderful colleagues who have helped ensure the quality of care I would want for my own loved ones is maintained in each institution. Inpatient medicine is only a part of the role we as physicians fulfill, whether it be at MGH or at community hospitals, or health centers. I think being honest about both what you can and cannot do yourself is part of what prevents any of us in healthcare from burning out.

      I appreciate that MGH allows me some help so I can do the other things required to do my job- things like see patients in clinic, create treatment plans, meet with families, serve as quality committees, conduct clinical research, mentor new fellows, supervise students (themselves in training to be MDs or NPs), and to write (papers, blogs, and new clinical trials). Inpatient medicine, as I stated, only a small fraction of what I do.

      My blog was not meant to trivialize the role of NPs or other health care providers, but to celebrate them. I hope one reading that blog does not in turn trivialize the role of physicians in oncology and in medicine.

      Thanks, D

      • Charlie Buscemi

        I applaud you for supporting NPs. Just do not call us “non-physician” providers. We are trained as independent practitioners and in many states practice as such.

        • drdondizon

          Dear Charlie, Thanks for your note. I appreciate the work you do and certainly intended no offense. I truly believe in NPs as partners in healthcare. I don’t view the role you and NPs in oncology as antagonistic in the slightest bit. Best to you,
          D

          • Charlie Buscemi

            Thank you for your thoughtful reply. It’s a shame that many of the comments are a bit harsh (including mine). It just seems around every corner NPs are trying to carve out our niche while organized medicine wants us to remain status quo. The reality there should be no supervision, just collaboration and partnerships. Thanks

          • drdondizon

            No worries- they call it “oncopolitics” when it’s specifically applied to oncology. It’s a shame really. But, I totally get what your stance on the whole issue. Partnership is key- totally agree. DSD

          • Jason Simpson

            Dizon you still dont get it. Charlie doesnt want to work with you. He wants your job. He thinks he is better at it than you are. Maybe he is right. But make no mistake — he does NOT want a “partnership.”

          • Charlie Buscemi

            actually you’re wrong. See, Dizon is an Oncologist and NPs need him and other specialists to refer to. Where we want independent practice is in Primary Care. NPs should NOT be practicing independently in speciality services. This is the domain of medicine not nursing. In these areas, NPs should and must collaborate with physicians, and even be supervised in highly specialized areas. thanks

          • Guest

            If one doesn’t need a medical degree to act as an independent doctor, why does one need a nursing degree to act as an independent nurse? A lot of nursing assistants and home health aides probably reckon they could do your job just as well as you. That doesn’t necessarily mean it’s in patients’ best interests to let them.

          • Mengles

            The nursing lobby’s interest and those such as Charlie, could hardly care less about patient’s interests.

          • Mengles

            Yeah, is that why NPs are setting up “fellowship” programs in Dermatology and GI? You guys should really get your talking points straight.

      • Dr. Jess

        “I am unclear how my post became an ‘us’ versus ‘them’ argument of NPs versus MDs”

        It happens every time, whenever there’s a post mentioning mid-level/non-physician providers. It’s not your fault :-)

        • drdondizon

          Dr. Jess, just wanted to say thanks again. Sometimes it is hard to not personalize the criticisms when it concerns something you’ve written. But I think it’s important to engage- so no regrets here!
          :-) DSD

          • Suzi Q 38

            Ignore them, Dr. Dion.
            I liked your story.

        • Charles McLaurin

          Thanks Dr Dizon
          Competence, compassion, professionalism, and collaboration are the pillars of good healthcare but not always see in these turf squabbles.
          Charles ACNP

      • Suzi Q 38

        You are too kind, Dr. Dizon.
        My daughter is studying to be an NP.

        • drdondizon

          Dear Suzi Q 38: I am certain with you as her mother she will be a truly empathic and wise one too. Hope you are well, DSD

          • Suzi Q 38

            Thank you Dr. Dizon. She is truly good at what she does. Helping others.

  • Charlie Buscemi

    PIE!!! nom nom nom…..”waa waa waa, mommy the big bad NP is taking over my turf”

    • Guest

      As a patient, I’m really put off by the childishness and pettiness of many of the non-physician providers whose comments I read on these blogs. Y’all don’t come off as professional medical practitioners in the slightest, but rather as jealous wannabes with chips the size of Idaho on your shoulders.

      For heaven’s sake, if you want to be taken seriously, grow up.

      • Charlie Buscemi

        my sentiments exaclty. I am just using a child like post to illustrate how riduculous some physicians behave…THEY have made this a “turf war”..we just want to care for patients. thank you

        • Cyndee Malowitz

          You are 100% right Buscemi! If we don’t stand up for our profession, then no one else will.

        • Jason Simpson

          Your CV says that you got a “Practical Nursing Diploma, Lindsey Hopkins 1989, Miami, FL”

          What the hell is a “practical nursing diploma”? Sounds like a nursery school diploma mill to me.

          And you want us to call you “doctor”? LMAO

          • Charlie Buscemi

            oh God…a stalker!

      • Cyndee Malowitz

        Ha! Have you read the childish and hateful comments that physicians leave on this site? Interesting that you’ve missed all of those…

    • Guest

      You and Jason are just as mature as each other. Lovely.

      • Charlie Buscemi

        You’re right Jess. I allowed myself to stoop to his level.

  • drdondizon

    Thank you for that!
    Best to you, D

  • Cyndee Malowitz

    Mengles – you know who we are, but WHO ARE YOU? You’re SUCH a coward…posting anonymous, hate filled comments towards NPs. There is just NO WAY you’re a physician. I truly believe you flunked out of NP school and this is your way to even the score.

  • buzzkillerjsmith

    Dr. D’s post has nothing to do with our primary care travails, and I agree completely with his sentiments that NPs do a wonderful job and are a great help in many practices.

    I just wish they weren’t going to put family docs out of business. Can’t have everything I guess.

    • Dr. Jess

      I feel a little bit sorry for Dr. D. His post has been hijacked by doctors and nurses engaging in internecine warfare which is not really related to the original post and in a manner which is probably better suited to Facebook.

      It seems like the comments section following any post which mentions non-physician/midlevel providers is destined to devolve into childish spit-balling between a few habitually aggrieved players.

      • drdondizon

        Hi Dr. Jess,

        Well, I was a bit taken aback by the commentary that really was far removed from the point of my blog. But, it has been really an interesting string of comments to follow.

        Thanks for your empathy- it comes across well on the blogosphere!
        DSD

      • buzzkillerjsmith

        “…destined to devolve into childish spit-balling ….” Very well put.

    • drdondizon

      Thanks for seeing what in all honesty was my intent- to highlight the great job NPs do and how much we do need them in medicine. I think collaboration is critical- unfortunately, maybe because I didnt make the “equality” between what I do and what NPs do, that seems to have been lost in the subsequent conversations.

      I think the key is not so much NP or MD (or NP and MD for that matter) it’s all about access to quality care, but as important are that relationships matter- between the doctor and patient, clinicians and administrators.
      DSD

    • Suzi Q 38

      I don’t think that they are going to put you out of business.
      You and many others have already stated that there is a shortage of family doctors in virtually every city.
      If so, why worry?

  • querywoman

    English is a naming language, what that means is that having a name for everything is very important. If you have studied French or Spanish, you know that English has a very simple verb.
    Nurse practitioners and physician assistant’s ARE non-physician providers. Any similar term might irritate some people. To avoid confusion, it would be best to call them nurse practitioners or physician assistants. In a medical environment, most people understand the terms, “NP,” and, “PA.”
    There is also a tendency in English to shorten nouns or refer to them by alternate names.
    What’s non-offensive? Physician extender?
    It’s impossible to please everyone.
    I see D.O.’s as well as M.D.’s, and lots of people don’t know what a doctor of osteopathy is.
    A chiropractor is a doctor, but not licensed or trained to prescribe meds or do surgery. whereas a doctor of dentistry is!

    • drdondizon

      Dear Querywoman,
      Thank you for your post! I found them both interesting and quite thoughtful actually.

      Best- DSD

      • querywoman

        Dr.Don, I have a not-so-worthless English degree. I learned in linguistics that English is a “naming” language.
        In effect, if a NP or a PA can prescribe drugs and do surgery, they hardly differ from a medical doctor.

        • drdondizon

          Dear querywoman, had I not going to medical school I would’ve pursued my second passion- English literature; either that or Religious Studies. My liberal arts courses remain some of my happiest remembrances from college. AS for the NP/PA versus MD debate, I am not taking part in it and I never intended to. I think mostly because I am a specialist and as such, fairly removed from the dilemmas and politics of meeting the needs of primary care. DSD

          • querywoman

            I agree that your statements had nothing to do with NP/PA debate. I just tossed that in.
            I have 2 specialist offices, for endocrinology and dermatology, that utilize PA’s and NP’s.
            My endo office is a good example of how to utilize PA’s and NP’s. It’s a 2 doc chain, Dr. 1st and Dr. 2nd.
            When I first saw Dr. 1st, he was alone and had an NP or two. His office was about to burst apart at the seams, because there were no other endos in our part of town.
            I kept asking if he was going to get another doc. I heard stuff like he was trying to hire a VA doctor when she got a full outside license. That never materialized.
            The last time I saw Dr. 1st, I was doing well, and he suggested I see his NP next and them him after that. I was cool with that because he was so overworked.
            One I missed 2 appts. with Dr. 1st. I called for a new appt., and was asked if it had to be with Dr. 1st. I said, “No,” and they gave me an appt. with their new doc, Dr. 2nd.
            Dr. 2nd has me on new diabetes drug about which I wrote elsewhere and am doing marvelously with significant weight loss, and serious pneumonia last year. So far, he has only seen me himself. I am a complex patient, though doing quite well. He has also tinkered with my thyroid med slightly. I don’t think Dr. 2nd wants to assign me to a PA right now.
            Now, today I did a follow up with my pulmonologist whom I met up with in the hospital. He sees patients in the office only 3 afternoons per week..
            As I checked out, I commented to his receptionist, his only employee, that I had figured out my bill from the Medicare statements since she had never sent me a bill. She said something about having 10,000 patients and that he worked 7 different hospitals.
            Does he sound overworked? He seems to be a good doctor!

  • Charlie Buscemi

    I have to admit, this thread has been fun. The reality is that NPs would NOT exist if physicians wouldn’t have abandoned primary care. MDs realized they needed to specialize in order to afford the McMansion, Mercedes E class, and trips to Europe. NPs just seized an opportunity. Now medicine wants to fix what they themselves broke. Sorry, but it’s tool late. That train has left the station. Physicians have allowed to many years go by before trying to recapture what they left behind. Too many years that now demonstrate the value (both human and financial) NPs have. Too many studies demonstrating how we are safe and just as effective in primary care. Too many patients who live in rural areas where an NP is their PCP who now would never switch. So to my physician colleagues, instead of fighting us, support us, join us. You never know, you just might need us to hire you one day.

    • Dr. Jess

      Are you all right? Your comment has nothing to do with anything the author wrote in his original post.

      • Charlie Buscemi

        You’re right. Has nothing to do with blog. Clarifying from some threads further down. Thanks

    • Jason Simpson

      Sorry dude you’re still just a male nurse. I’m sorry you are so broken up over that. You can try to hide it with a white coat or claiming that you got some fake doctorate that nobody respects that you got out of a cracker jack box, but at the end of the day you are just a male nurse. I know this bothers you but you need to get over it and DEAL WITH IT! LOL

      • Charlie Buscemi

        I know the “Jasons” of the world…old bitter, washed up MDs who due to their incompetence have been replaced by an NP…LOL…

        • Orin Scrivello

          A nurse cannot replace a doctor unless he or she goes to med school and earns an MD. Just like a dental hygienist cannot replace a dentist unless he or she goes back to school and earns a DDS or DMD.

          My dental hygienist is lovely, and we could not function without her, but we would not want her to start removing impacted wisdom teeth on her own.

          • Charlie Buscemi

            with all due respect you are wrong. comparing a Dental Hygienist with a Dentist is comparing apples to oranges. While with in NPs and MDs in Primary care, we do equal work. So yes, we can replace them in a primary care setting…I know because I have.

          • Orin Scrivello

            A nurse can pretend they’re a doctor, just as a dental assistant can pretend they’re a dentist. Alas, reality is a harsh reckoner.

          • Charlie Buscemi

            again, wrong. we dont “pretend” to be doctors. (btw I have a PhD so I AM a doctor). NPs just are very skilled at providing primary care as many studies have demonstrated. Just stop and think for a second…why is the NP flourishing? why is it so important and central to the Afordable Care Act? Cost and Quality services. If MDs would have not abandoned primary care, we would not even exist.

          • Noni

            I think the point being made is yes, you can do equal work, but is the quality the same? You say so. Others disagree. That level of disagreement is something you’ll always have to tolerate.

            Personally, I have no issue with independent NPs in primary care. The only thing I wish is that there was some sort of standard available (either with regards to education or certification) across the board. I think if NPs want equality they should be willing to prove they are equal in ways physicians currently must now: complete standard board exams and licensing requirements.

          • Charlie Buscemi

            Thank you for your reply. The thing is Noni, nursing is a discipline unto itself, housed in institutions of higher learning, governed by its on boards of nursing, board certified by our own credentialing agencies. This is not about “mimicking” medicine but providing our own unique quality and level of care. Which in the primary care setting is equal to, or as some studies have shown, better than the care of physicians. We provide advanced nursing care not medical care.

          • Noni

            Thank you for the clarification. Personally, I remain skeptical, and it will be fascinating what long term outcomes will show. Time will tell.

          • Charlie Buscemi

            i agree. again thank you

          • Guest

            Hmmmm….Somehow I don’t think “separate but equal” is what you are aiming for.

            And something seems odd in using “advanced nursing care” to manage hypertension, diabetes, hypothyroidism and the like. Would the end result fall somewhere between medical care and nursing care? Then doesn’t it seem the quality is beneath that of sole medical care?

          • Suzi Q 38

            Talk about quality???
            My story is redundant, but I had some supposedly skilled specialists caring for me for the last 2 years and had undiagnosed spinal stenosis.
            All I needed was an MRI of my c spine to diagnose
            my problem.
            I don’t let doctors get any with “see you in two months…” without giving me some answers or some treatment anymore.
            My point is that sometimes quality is not necessarily a given with a medical or specialist’s advanced degree.

          • SBornfeld

            Can you point me to specific provisions in the ACA referring to independent practice of NPs? Thanks.

          • Mengles

            You are a PhD, and thus a doctor, but not a MEDICAL doctor. That’s the difference. Even college professors with PhDs don’t have the hubris and stupidity that you do. You’re “flourishing” bc of your nursing lobby, and nothing else. Funny how you don’t mention that your DNP colleagues are now trying to infiltrate specialty care as well.

          • Charlie Buscemi

            Oh look, Mengles. You’re probably another washed up bitter old MD who was booted out of practice due to incompetence and was replaced by a shiny new NP…poor you :( lmao

          • Mengles

            No, actually I’m not. But please keep believing that. I’m more than happy to see the malpractice lawyers gobble you guys up.

          • Charlie Buscemi

            OMG you are such a loser on so many levels…lmao!!

          • Suzi Q 38

            Time will tell.
            Aren’t you confident about your own skills and abilities to worry about a few NP’s?? You sound a bit defensive and insecure.

          • SBornfeld

            Well, the reality is that whatever they claim is supposed to be explicitly laid out in the state medical and dental practice law. So, whatever you may personally think of their relative qualifications in primary care, they can claim whatever the state law says they can claim.
            The defensiveness of physicians is to me totally understandable. Whether state law will ultimately allow independent practice of alternative providers, or an incursion into medical practice by non-medical providers (doubtless in an effort to cut costs) remains to be seen.

            For all I know, there may actually be evidence that in specific settings, NPs can be equally effective as MDs; or not. I think it’s safe to say that however this shakes out, someone’s going to be very unhappy. Hopefully, it’s not the patients.

          • Noni

            Two things I have observed in mid-levels (sorry for the blanket term but for the sake of brevity I use it) are (1) very textbook approach to medical care and (2) a very narrow field of knowledge (physicians do learn and see tons more during longer and more arduous training – no denying that). You may hear that “NPs don’t know what they don’t know,” and this is very true. If you don’t learn about obscure or unusual presentations of common things, how will you know they exist?

            The question is whether or not midlevels are open to acknowledging their shorter training, open to being mentored and open to life-long learning. The ones here seem to have huge chips on their shoulders and claim their knowledge is at par or superior to that of physicians, but are they ok with asking for advice? That’s what I worry about.

            In my 2 experiences with independent midlevels, both were confident in their proposed treatment plans and both were completely wrong. That can happen with docs too, but because of this experience I am skeptical about independently practicing midlevels.

          • SBornfeld

            Well, there are plenty of chips to go around.
            I can’t speak to relative competence–I’d guess that context here is everything.
            As far as “textbook”, I think that’s likely to be the case with any young practitioner. Clinical experience ought to take care of that (as it did for me).
            My limited experience is ancient (my residency, 36 years ago) in the ER–there were 2 PAs there, both more competent (at least surgically) than the moonlighting internists and (gasp) anesthesiologists. But that’s a pretty well-circumscribed situation–I’m sure most of the patients didn’t even know they weren’t physicians.

          • Molly_Rn

            Or a chiropractor can claim to be a doctor when they are a quack.

          • SBornfeld

            You should know that dental hygienists have long lobbied for the right to practice independently in primary dental care.
            Explain to me–my understanding is that the training for an NP is considerably quicker than for an MD. If you’re saying they are essentially interchangeable in primary care, I infer you think that either MDs learn a lot of unnecessary stuff, or that NP programs are just a whole lot more efficient in producing practitioners of equal effectiveness. Or…what am I missing?

          • Guest

            Pardon my ignorance, but are hygienists wanting to do annual exams and fill cavities? What constitutes primary dental care exactly?

          • SBornfeld

            Hygienists have for some years been lobbying for independent practice in a number of states. The bigger “midlevel provider” issue of late is the so-called “dental therapist”. The actual parameters of these mid-level providers varies somewhat from state to state. For that matter, the level of “supervision” that is acceptable even in states without expanded functions varies. I’m not an expert here, not because I am not concerned with access issues (I am) but because I’m too old and grouchy to put up with the yelling and screaming.
            So what am I doing here? Good question.

          • Mengles

            Then you should be able to do so based on your merits and education, not based on lobbying and strong arming politicians.

          • Cyndee Malowitz

            Mengles – if you don’t like the laws, then MOVE TO ANOTHER COUNTRY. NPs will continue to practice independently whether you like it or not.

          • SBornfeld

            I wouldn’t remove impacted wisdom teeth on my own either.
            When I graduated, it seems you heard about nothing but denturism. Now it’s “dental therapists”. Plus ça change…

          • Cyndee Malowitz

            NPs have already replaced family physicians in several states and they did it years ago. You didn’t even know that?

          • Noni

            No, probably the same way you didn’t know dental hygienists are trying to replace dentists. Don’t assume everyone knows what’s happening in health care.

      • Suzi Q 38

        Boys, play nice in the “sandbox.”

      • Kathleen Kettles

        That’s right he’s still “just” a male nurse but you my friend are just “a lady who doth protesteth too much.”

    • Mengles

      Studies funded by the nursing lobby, with as many holes in study methodology as swiss cheese. I have a study that shows that 5th graders given enough training are equivalent to DNPs.

      • Suzi Q 38

        Maybe their outcomes are equivalent to physicians as well. Your claim is ridiculous.
        Share the study, please.

      • Cyndee Malowitz

        Mengels – The reason NPs are so popular is due to GREED on the part of the physicians. GREED b/c they invented our profession just so they could see more patients and make more money.

        The Texas Legislature just passed a bill that will increase the number of NPs physicians can “supervise” to SEVEN. So, now the physician can bill at the “doctor rate” for SEVEN full-time NPs! The physician never has to lay eyes on the patient nor review a single chart. What a DEAL for doctors! Even more interesting, physicians can “supervise” an UNLIMITED NUMBER of NPs in medically underserved sites. Ummm…1,000 NPs per doctor, that sounds about right, don’t you think?

        One last tidbit, the Texas Medical Board doesn’t hold physicians accountable for NP’s errors unless they were directly involved in the patient’s plan of care. Talk about having your cake and eating it too!

        • querywoman

          Some unethical doctors will delegate down their services to 7 NP’s – aaaggh! And the docs will sit on their duffs and do admin fees and collect the money.
          “Real” doctors will continue to see patients on their own and might add a NP or two to extend their practices!
          There are bad and good apples in very professions!
          Since I live in Texas, I better complain to the politicos for this one!

        • Cyndee Malowitz

          I wonder why my comment got all the thumbs down? Do you guys not agree with this new law or are you just mad that I pointed it out to the public?

          • Guest

            I think people don’t like YOU.

    • querywoman

      I am puzzling about the explosion of NP’s and PA’s. My family moved to a large urban area about 40 years ago, and started using DO’s. My first DO told me that DO’s were heavily into family practice, and that MD’s had got away from that.
      There are DO specialists now too. I went to a DO endocrinologist once who didn’t know squat about general medicine.
      I’d just really like to know what sprogged the grown in NP’s and PA’s now, since so many docs have them.
      Yet, most physicians still work ungodly hours, and medical students and residents still go through routine sleep deprivation!

  • querywoman

    Dr. D, my mother died of lung cancer. I assume her oncologist’s practice was similar to yours. He was part of a doctor chain and had one PA.
    He told us once that he was going to visit his home country for a month with his wife and small children and see his own mother. I told him we wanted him to see his mother. He said she could see his PA while he was gone.
    I took her to the PA visit and stayed with her. The visit was fine, and the PA was fine. I suppose she could have seen another doctor in the chain, but the PA practiced under/with him and probably was familiar with his ways.
    Most cancer docs seem to have plenty of patients.
    I see a dermatologist, a teaching, research, and treating doctor who has a large clinic with residents all the time and a few PA’s. The other dermatologists’ names on the door come and go. They learn with him and eventually go elsewhere.
    I have seen his PA a few times for bandaging treatments, etc. His office prefers that I see the PA only when he is in the office. She went and got him once when I still looked pretty raw after we unbandaged my arms.
    It’s obvious that he does not abdicate his professional and legal responsibility to his patients to her. I have know of a few docs who let the PA’s and/or NP’s see most of the patients and even upcode the services at times.

    • drdondizon

      Hi Querywoman, I think you’ve pretty much summed up the collaborative practice of medicine that I am grateful to have had access to, in the past and today. The NPs I have worked in the outpatient clinic had their own schedules, and it did include some of my own patients. Sometimes it was by sheer necessity, but other times it was by my own patients’ requests. But I always knew that if my NPs were not sure of something or needed a second opinion, I could trust them to ask. And more importantly, my patients knew I was still involved- very much so. DSD

      • querywoman

        Let’s discuss a little more. Are your NP’s allowed to prescribe chemo, some of the very strongest drugs available, and radiation?
        I can speak more about how my derm using his PA than how his endos do. He’s been practicing a very long time. The fact that his office prefers to schedule me with his PA only if he is in the office is very telling.
        Sometimes the PA comes in on my office visits with him, along with a couple of residents and/or medical students he has with him. So it seems he has strong supervisory/working partnership, and she knows he is always available.
        I know that my dermatologist and 2 endocrinologists like to see their own patients and don’t want to delegate it all down.
        What we are discussing here also has very little to do with the ongoing discussion about mid-levels in primary care!

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