In the battle for primary care, both doctors and nurses are to blame

Apparently the Affordable Care Act has inspired panic among some physicians groups worthy of the fear historically reserved for deadly epidemics. From the articles I read, these groups are wringing their hands in hysteria over what to do and how to survive. One solution that has apparently gained popularity  in these circles is the  launching of campaigns against one of the most logical solutions, nurse practitioners.

Last fall, the medical association in my state purchased large blocks of advertising space to alert the public about the importance of knowing who’s treating you. They emphasized that “only physicians have the comprehensive diagnostic, pharmaceutical, and patient care background” (apparently) necessary to successfully treat the public for every malady from a hangnail to a heart attack. All this from within a state with some of the most dismal physician retention rates in the nation.

A simple Google search will enlighten anyone that we have enough people in need of health care to go around in this country. Yet, some physicians will argue that NPs do not possess the educational background nor the clinical experience to provide primary care to a portion of the soon to be 17 million newly insured Americans expected to flood waiting rooms come January one.

Access to care has become the new catch phrase and it has gained a momentum that threatens to roll downhill like the proverbial snowball headed toward a very hot place. The fears and suspicions directed toward NPs by certain insecure factions of the medical community does nothing to instill confidence in heath care in general and only serves  to insure an even more fearful and confused public.

Some campaigns touting  physician care as the only acceptable choice have simply backfired. Both lawmakers and the public at large are growing weary of those members of the medical profession who apparently want it all, and then, in the next breath wail that, with the ACA looming large on the horizon, they can’t possibly take care of it all. Such  logic would confuse Aristotle, cause Hippocrates to shake his head in disgust, and inspire Florence Nightingale to offer up a weary smile while Clara Barton would in all likelihood prefer to take another bullet through the shoulder of her dress than attempt to wring sense from this schizophrenic argument.

Advanced practice nursing  groups must also accept a portion of the blame for the battle. They lash back at every perceived slight by brandishing white papers, research studies, and reams of patient testimonials, thereby assuring a merry-go-round of futility that continues to spin out of control.

Now is not the time to cross swords. It behooves both professions to pause and think. Analysis of  any new process, such as the ACA, can be a prudent and productive step toward preparation, but the inspiration provided  by innuendos and rumor is an exercise in futility. I use the terms innuendo and rumor with regard to the ACA inspired hysteria. Because we do not know how reform is going to play out until it  actually begins to play. Roles cannot possibly be defined at this juncture. All involved badly need a superiority check.

Experienced NPs are capable of providing quality care for the majority of Americans. While entering this profession does not require a medical degree it does require an exceptional amount of fortitude and intelligence. I have heard that medical school is competitive, brutal, challenging, time consuming, and difficult. So is nursing school. Much has been made by some who represent the medical community about our lack of clinical residency hours compared to those of even a newly minted physician.

Yet, I know many NPs, like myself, who practiced as an RN for over two decades before returning to school to earn the graduate degrees that allow us the privilege to expand the parameters of our practice.

Yes, some NPs lack experience, so do some physicians. Some are better at what they do than others. The same is true of physicians. I have seen cases where patients have been  misdiagnosed by doctors and mismanaged by NPs. I have also seen shining examples of brilliance from the very best of each profession.

I like to joke that I did a thirty year “residency” before striking out on my own as an independent NP. I won’t even attempt to translate that into clinical hours , but I feel safe in assuming that most neurosurgeons have far fewer under their belts when they hang out their first shingle.

Apples and oranges? Some will say so. Still, if quality patient care is the big concern with regard to preparation for health care practice, then most NPs have  it. Few inexperienced NP graduates will seek independence right away. Most will work for physicians or under the tutelage of more experienced colleagues, allowing them to continue their educations. I spent my first twelve years as an NP working side by side with several physicians in a large multi-specialty practice before I even considered striking out on my own. I gained a wealth of knowledge during that time and I am grateful for the skills that were taught me  by those mentors.

It is time to work together as never before. Both our professions have much to give and  both possess the expertise to give it. No, the educations are not the same, but the goals are.

I respect physicians. I consult them when appropriate and they refer patients to me. I acknowledge their sacrifice of time, money, and self in pursuit of contributing to the greater good. I like to believe they respect me for those same sacrifices. I applaud those who support NP practice and acknowledge our profession as instrumental to the success of expanded care. I congratulate all those who put patient care above personal insecurities  and project genuine concern for patients.

I am a nurse. My practice comes from the very heart of nursing. I am not a doctor wannabe, but make no mistake, I am a doctor “could have been,” just as surely as I might  have been an astronaut or a Supreme Court justice had medicine, aerospace technology or law been my interest rather than nursing. My NP practice is something that evolved over thirty years of experience and it was the next logical step in my professional development.

I strive to provide  my patients with the best evidence based care while implementing  the nursing model as my guide. Often, I do this unconsciously, so ingrained  is this philosophy into my psyche. My thought process may differ from that of the medical model, but it will lead me to the same conclusions, plans of treatment, and patient outcomes.

As we await the coming storm that is the ACA, I believe both professions need to re-evaluate who we are and what we each have to contribute to improve heath care in America. Pulling together with mutual respect is a far better option than fracturing our talents into millions of useless pieces as we struggle to gain a foothold in this battle for primary care.

Kim Byars is a nurse practitioner and founder, Byars Family QuikCare.

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  • Anthony D

    “Apparently the Affordable Care Act has inspired panic among some
    physicians groups worthy of the fear historically reserved for deadly
    epidemics.”

    When we have millions more entering the system AND a number of doctors retiring because of Obamacare (and some that are not have decided they will go to “cash only” and will not accept insurance due to the massive
    and cumbersome Obamacare law) you won’t be able to average one day for an appointment like you and I can now. Be ready for weeks if not months delays in appointment.

    And it MUST be that way. Adding millions of new patients but REDUCING the number of doctors and, well, you do the math.

    • southerndoc1

      Please specify what in Obamacare will make the already grotesquely cumbersome for-profit insurers so much worse that physicians will go “cash only.” I don’t see it.

      • M.K.C.

        Thank you. A fair few people seem to be unwilling to admit that our health insurance/healthcare system was already broken before the ACA was signed into law.

        It’s not like we had this perfect shining system, and then Obamacare came along and ruined everything. It was only because what we had was pretty flawed that the American people gave Obama a mandate to “fix it”.

        N.B. I was not actually one of those people, I didn’t vote for Obama, and I don’t actually think Obamacare is going to help matters any — but fair’s fair. I think Obama’s critics should confine themselves to blaming him only for things that are actually his fault.

        • southerndoc1

          Exactly.
          When I ask fellow docs for specific examples of how Obamacare has or will make their work miserable, they come up with some policy that United or Aetna put into place a decade ago.
          Go figure.

          • SBornfeld

            LOL–are you saying that physicians are as politically sophisticated as the rest of us?

    • Suzi Q 38

      Yes, I agree with the time it may take to see a physician.
      I will have to make my appointment with my PCP 2 months in advance, and If I need to see a medical professional sooner, I may have to call a different doctor, to to the urgent care, or see a dare say it….midlevel NP.

      That is fine with me. I will catch up with my doctor in two months, but see my NP today or tomorrow.

      Maybe not preferable, but I will do what I need to do.

  • Close Call

    “Battle for primary care”… heh. That’s funny.

    I didn’t realize people thought primary care was something worth “battling” over. Doctors don’t seem to want to do it… and neither do many NPs.

  • Mengles

    I like to joke that I did a thirty year “residency” before striking out on my own as an independent NP. I won’t even attempt to translate that into clinical hours , but I feel safe in assuming that most neurosurgeons have far fewer under their belts when they hang out their first shingle.
    =======================
    The absolute arrogance of comparing the number of hours of playing doctor to a neurosurgery residency is mindboggling.

    • Jess

      That’s what really scares me about so many of these midlevels. Their arrogance, their hubris. They actually do believe that they’re just as qualified, or even better qualified, to practice medicine, as doctors.

      A nurse who has been a nurse for 30 years has 30 years experience at being a nurse, and that’s all. He or she still cannot compare himself/herself to a doctor, for he or she is not a doctor and never has been.

      It’s like someone claiming that because they have had a driver’s license for 30 years, they’re just as qualified to fly a plane as any licensed pilot.

      Apples, oranges. Mindboggling indeed.

      • FugaziedUp

        By “midlevels,” do you mean “NPs”? Because they are the only midlevels i see on these blog posts equating nursing care to the care provided by a physician, or anyone trained in the medical model for that matter. PA’s seem ro be unfairly lumped into this discussion. They maintain and assert their status as dependent practitioners. And many seem to be stronger clinicians and have much more experience practicing in the medical model than the NPs on here

        • PCPNP

          I am not sure why you posted this? For the most part, NPs are not dependent (depending on what state you are in). Not all PAs feel as you do about dependence. Why would you make a statement like “PAs SEEM to be”. How did that add positively to this discussion?

          • FugaziedUp

            There is much angst directed towards midlevels from physicians. PAs dont seem to be asserting themselves as the answer to the primary care shortage, nor as independent practitioners who can do everything a physician can do. Additionally, the educational structure and postgraduate degree structure for PAs is considerably different from NPs. My point is that “midlevels” is a poor generalization for two considerably different practitioners and most of the angst from physicians should be appropriately directed. Apples and oranges

          • Guest

            I can only insert my personal experiences here. PAs, like you said, seem content to assist and work with physicians. One of my dearest friends is a PA (I’m an MD). I’ve never heard her claim to be as good, as educated or as competent as an MD. She works hard, works in a supervised role and has a great attitude.

            There may be some smart NPs out there, but any intelligence they have is lost in their arrogance.

          • Disqus_37216b4O

            My doctor’s PA is excellent, I have no qualms about seeing him rather than my doctor for most things, because he doesn’t hesitate to call her in if he’s not sure about something or just wants confirmation that she agrees with his course of action. They really are a good team.

            I think any medical provider with a chip on his or her shoulder is a dangerous thing, whether it’s an NP or PA or an MD (I did have one doctor once who seemed slighted and got churlish about my desire to seek a second opinion).

    • Guest

      Comparing herself in any way to a neurosurgeon is just so perverse. I am a physician and I certainly would never be so arrogant as to say I’ve accomplished more than a newly minted neurosurgeon.

      Good God.

    • macbook

      I completely agree. There are so many arguments in this article and analogies that literally make no sense that they eliminate any legitimacy to the authors points. There is no comparison of nursing school to med school. I can’t even believe anyone would even think to write that. The level of arrogance is scary…..

  • buzzkillerjsmith

    For the love of God, please do not comment any more on this thread lest we wind up with a hundred or more vociferous yet mostly pointless comments guaranteed to irritate most and illuminate none. You have been warned.

    • ninguem

      or at least make some popcorn

    • Suzi Q 38

      No kidding.

    • Disqus_37216b4O

      Someone on one of these posts a while back described the comments sections of threads like this as “inevitably descending into spit-ball fights between doctors and midlevels” (paraphrasing).

      That image has stuck with me. LOL.
      ~~patooooie!~~

  • Mengles

    New MS-1s you’ve been thoroughly warned. You better hit the ground running and buy First Aid NOW and work damn hard for 4 years. If not, you will pay for it for the rest of your life.

    • Jason Simpson

      Mehhh….. not that worried.

      I know a doc who opened a clinic directly across the street from a nurse practitioner clinic. He advertised that people got to see a real doctor there, and within 3 months the NP owned clinic (which had been there for over 10 years) folded and went into bankruptcy.

      MDs have an enormously valuable credential that cant be devalued by NPs, even if they are “independent”

      All things being equal people will choose MD over NP, ESPECIALLY since NPs are apparently going to get paid the same as MDs by insurance companies under ObamaCare.

      Why pay the same amount of money to see a stupid nurse when I can see a real doctor instead? NPs only make sense where they are cheaper and/or MDs are sparse.

      • Julz7777777

        Wow Jason, you make me laugh. Are you an adult? I certainly hope you are not working in a health care setting with NP’s or MD’s. You will get eaten alive with that attitude. I will pray some wisdom is bestowed upon or you will have a long miserable road ahead. Or maybe you are just miserable period and you are trying to make yourself feel better by trying to belittle others?

      • crnp2001

        As usualy, Jason, your “intelligence” shows by your comments.

        “Stupid nurse?” Get over yourself. And for anyone else that tends to “like” his comments, that shows your own value as well.

        • Margaret Houlehan

          Isn’t he OJ’s son? LOL

      • Adolfo E. Teran

        Dear Jason, I think in order to let others see your point, you do not have to offend the readers. You have the right to agree or disagree but there is not need to be vulgar or call names. If you do not like NPs then you do not see one ir you like MD/DOs then see one. I think it is simple.
        Adolfo E. Teran, MD

      • Cyndee Malowitz

        Jason – I own a minor emergency clinic and a D.O. opened another minor emergency clinic directly across the street. He even advertised that his clinic is “staffed by a physician.” Well, guess what…I’M BUSIER and have been competing with him for 3 years now.

        BTW – I just hired a NP due to the fact that we’re busier than ever and we’re in the slow season. So much for your claim that patients would choose a MD/DO over a nurse practitioner when given the choice. My patients pay the same co-pay whether they’re treated by a physician or a NP.

  • Suzi Q 38

    “…..Some campaigns touting physician care as the only acceptable choice have simply backfired. Both lawmakers and the public at large are growing weary of those members of the medical profession who apparently want it all, and then, in the next breath wail that, with the ACA looming large on the horizon, they can’t possibly take care of it all….”

    I agree with this statement.
    There is going to be a huge PCP shortage, no doubt about it.
    Moreover, the PCP’s keep reminding us of this soon to be reality.

    It makes sense that they are going to have to have an alternative means with which to serve the public.

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

      Aww poor babies, so now NPs hate doctors and hate payors a.k.a. insurance companies as well. Funny how in the article, they have to run to Obama to force insurance companies to accept them, rather than be accepted on their merits.

    • PCPNP

      Are you a physician? Why would you light it up? What is your motivation for doing this? Do you have a financial interest in the medical profession? Just wondering.

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

        Doing what? Informing the discussion with a new article from Kaiser Health News, which is fairly balanced by the way?
        All I have is a passing interest in the medical profession as it pertains to the welfare of people, regardless of ability to pay. How about you?

        • PCPNP

          Informing the discussion by encouraging others to light it up? With gasoline? Or a “well balanced article”? A passing interest? Me? I am a Nurse Practitioner.

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

            Good for you. Then I am interested in your opinion…. Did you not find the article well balanced? If not, what would constitute a well balanced article in your opinion?

            BTW, since these threads usually turn into a futile fist fight every single time, this was supposed to be an anticipatory humorous remark…

          • Disqus_37216b4O

            So far, at least 7 of us have understood and appreciated your point, Margalit :)

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

            Thank you :-)

  • Jason Simpson

    Why would I pay a $40 copay to see a nurse when I can see a real doctor for the same amount of money?

    • Disqus_37216b4O

      If we truly had a free market in healthcare, doctors, NPs and PAs could all set up their own practices, set their own prices, and let the market work it out. There might be an NP and an MD across the street from each other, and the NP charges less than the MD does. That being the case, and patients actually using their own money for their healthcare needs, there would be those who’d choose the NP’s practice for many routine needs, and there’d be those who absolutely positively want to see a doctor every time, so they’d be willing to pay for it.

      But there might be cases of an exceptional PA or NP who does such a great job and inspires such loyalty that patients are clamoring to see them, and they might even start charging more than the MD across the street. And those who really valued that PA or NP would be willing to pay the premium to see them.

      It’s the third-party payor system that messes so many things up.

    • crnp2001

      Because perhaps, just perhaps…you would get quality time, evidence-based practice, and just as good, if not BETTER care by a NURSE PRACTITIONER. Let me be clear. We are NPs…not just nurses. RNs do phenomenal things in their own roles. We have advanced practice ones. Why don’t you come on down to my practice, poll my patients…or better yet, see both me and my doc and observe the difference…See which one of us gives you “your money’s worth.

    • Cyndee Malowitz

      Maybe you won’t, but thousands of patients have paid to see me over a “real doctor” and they continue to do so.

  • Dr. Casa

    PA’s and NP’s represent an economic threat to physicians in that they deliver care that previously required a physician, thereby placing downward pressure on physician compensation. Simple supply and demand. Physicians make a profound investment in their training that is largely unrecognized by the general public. Even if quality of care was comparable (not saying it is), resentment of mid-level providers by physicians is understandable.

    • FugaziedUp

      If the almighty dollar is your bottom line (which, from the looks of your post, it is) then i completely understand the resentment. But pssst…(whispering voice) there’s a primary care shortage. And the leadership of primary care physicians hasnt done enough to address it. Until they do, patients will look to anyone to receive the care they think they need, and the practitioners providing that care will expect compensation for providing that care

      • Dr. Casa

        I completely agree with you regarding the primary care shortage. I think much of the problem relates to the tremendous disparity that exists between compensation between primary care and specialized care, which drives people to pursue the latter. This affects mid-level providers as well. I recently read that 1/2 of NP’s and PA’s enter specialty fields.

        It is also my understanding that the US has about twice as many specialists per capita and half as many primary care providers as do most other developed countries. These countries continue to outperform the US on many important outcome measures at a fraction of the cost. Medical training in these countries is typically only 6 years as opposed to 8 here in the US and tuition is often subsidized by the government. I think a case can be made for shortening the length of training for US physicians. In fact, NYU and Texas Tech have reduced such programs for medical students going into primary care.

        Before completing my MBA and enrolling in medical school I worked as a CNA and EMT, during which time I developed an appreciation for the work done by those at every level of the medical hierarchy.

        My previous comments were merely intended to offer an explanation as to why physicians may be unfairly critical of NP’s and PA’s.

    • Cyndee Malowitz

      Unless of course that NP is working FOR the physician and the physician is getting reimbursed the “doctor rate” for the visits. Then, all of a sudden, the physician is DELIGHTED with the NP and the care they provide.

  • Anthony D

    “That’s what really scares me about so many of these midlevels. Their arrogance, their hubris. They actually do believe that they’re just as qualified, or even better qualified, to practice medicine, as doctors.”

    Its amazing how NP’s think they can do a better job then MD’s. Its like what’s happening in Anesthesiology! The CRNA’s feel they can do a better job then the Anesthesiologist while pushing for authority.

    The Private and Government insurance programs like them because they can pay them less while they get out of school faster! It comes down to is “how to pinch the penny even more”and its getting worse now in all specialties.

    It’s similar to what happen in the 1990′s when illegal immigrants were replacing union bricklayers because they were easy to replace and are cheaper to pay! Sounds a little similar with the NP’s huh?

  • Dave

    A business model (solo/small group primary care) that loses money for MDs does not magically become a viable model for anyone else. If the issue were MD vs NP when each hangs out their first shingle I don’t think anyone would get that upset. People who don’t like/mistrust physicians would gravitate to the NP practice just as others would prefer the MD and all would live happily ever after. But selling oneself to prospective patients is not the issue – it’s selling ourselves to prospective employers. It’s not about who provides adequate care, it’s about who can generate the most revenue for the least cost to the company.
    The way to “win” this for physicians is shift the debate to MD vs. corporation. Ad campaigns need to drop all mention of years in training difference and simply focus on greedy hospital CEOs who want to charge you for a doctor visit but “only” let you see a nurse. Whenever NP/MD equivalence bills pop up in statehouses, big hospital associations are some of the biggest lobbyists in favor. This is how we need to frame the battle, because in the end nurses are great people and everyone loves them, but nobody likes greedy suits who are out to rip them off.

    • southerndoc1

      Great post.

      For this to happen on a national level would require the leadership of the AAFP and the other primary care societies to pull their heads out of the asses of their corporate masters. Ain’t going to happen.

      On a local level, we find this a very effective argument to sell our practice: we get a lot of refugees from corporate/PCMH style practices, a couple of which are run by AAFP politicos.

      • Dave

        Perhaps a new organization then? Something like “Physicians for Healthcare Freedom” or similarly mama and apple pie while conveying the message that people should be free to see the caregiver of their choice, not the one the corporate suit says they can see.
        Could make an interesting Kickstarter campaign. If enough physicians feel the same way, could be possible to raise enough money for some advertising. Statewide buys are cheaper and could be targeted where legislation is being debated. Ad production is relatively inexpensive these days for something simple – maybe a documentary style interview with people whose loved ones were misdiagnosed by a non-physician provider. Targeting an older demographic more likely to utilize healthcare would also lower the costs as this group is less desired by advertisers as a whole.

    • southerndoc1

      As always, the AAFP’s position is nonsensical. They want to kill off private practice and force everyone into working for corporations, while the corporations are moving towards replacing all their primary care docs with PAs and NPs.

      Self-induced death spiral.

  • Milinda Houlette

    In all the comments, I have not read any doctor stating that they are willing to leave their lucrative practice in a metropolitan area and go to work in a rural area that is at least 40 miles from the nearest hospital of any sort. NPs have been willing to do this, and as the operators of family clinics in regions that are unable to have physicians of any sort, they are a God-send. There are enough practices for all of you. Right now, there are regions of the U.S. that would have no medical assistance if it were not for NPs. With all of the GP physicians that are retiring, I would think that the medical establishments would be thankful for the NPs being willing to fill in a gap that they have not.

    • Adolfo E. Teran

      Dear Ms. Houlette, I am not against NP’s or their practice. I think there are enough patients to all the providers. I think the one ultimately choosing is the patient. i also think that as long as I am free man, I have the right to choose where or how to practice Medicine. I actually went in a interview with Community center in a rural area. It was a joke, nobody knew details about the job offer. I even asked the director about it and she just smiled and walked away. Also Ms. Melinda if you have a perception that we as MD’s recieving money from the sky without working you got your facts wrong. I opened my practice and I pay taxes every time I breath, malpractice insurance the list is endless. I have to write a check for 4,000 today for my EMR hosting company.
      Adolfo Teran

    • Margaret Houlehan

      I know. It is almost as if some physicians and the general public are making the argument that if an MD or DO cannot provide the care, patients in underserved areas should go without care. Sad, and short-sighted.

    • Mengles

      And no NP/PA has ever stated they are willing to work in rural areas either. NP/PAs have the same incentives to work in large metropolitan areas as physicians. Don’t try to paint NP/PAs as somehow holier than thou when they aren’t.

  • Ava Marie Wensko George

    Dear Kim,
    Very well said. I’ve had the opportunity to sit on Nurse-Physician liaison teams working out issues between these two professions. I think the barriers are being slowly broken down and a mutual respect for each persons professional skill set is groundbreaking. Silos are still firmly in place with respect to job categories, but I am hopeful that the change in our industry will be the sledgehammer we need to break them down.

    • Kim Byars

      Many Thanks, Ava!

  • Dave Mittman, PA, DFAAPA

    A well balanced tome for respect and fair play.
    Of course SOME of the physicians on here, unfortunately would not understand that. Their loss.
    I would add that much of the above holds true for PAs and we too ave much to add and much care to give.
    Thanks Kim for putting into words what may of us feel.
    Dave

    • Mengles

      There’s a reason your title is Physician ASSISTANT and not just physician.

  • SBornfeld

    Let me preface this by saying I’m a lefty who favored a single-payer system.
    I also don’t DIRECTLY have a dog in this fight (I am neither a physician nor a nurse, but a dentist–and a patient).
    You’re right of course–that nurses and physicians share many common interests. Some of the exact same arguments have been used in dentistry against midlevels–first against “denturists” (legal in most or all of Canada, in Oregon, I think perhaps NH and maybe a couple of other states). This was a big deal about the time I graduated dental school in the mid ’70s. Later, the fight was against independent practice of dental hygienists. Now we’re hearing the same about dental “therapists”, who’ve provided care in a variety of areas underserved by dentistry. Somehow, we dentists continue to limp along.
    The arguments are never about money, of course. The argument against (for example) denturists is that they would not be able to recognize or properly refer patients with cancer.
    There is no question that the health professions are in for a tumultuous time. Some of us are going to get hurt.
    But in a day when the USPSTF questions the utility of the regular checkup, medicine has bigger problems than independent nurse practitioners. Attention should be paid to how education adapts, as well as legitimate ways to see that people who need care get care. You’re all still better working together to solve this rather than just taking what Congress doles out.

  • logicaldoc

    Let’s get real. This ongoing nonsense about how 7 years of Medical School training and intense Residency training is somehow anywhere near equivalent to NP “training” is simply an act of Cognitive Dissonance. When was the last time an NP picked up on post-glomerulonephritis? Or Wegener’s? Or even the difference between an acute cough of bronchitis versus one of CHF? Yes, maybe about 70% of the most common presenting acute complaints will be accurately diagnosed. What about the other 30%? If you’ve never seen it before; never been trained as to what it is, or what it may present like, by default, the diagnosis will be missed.

    • crnp2001

      You ARE kidding, right? Seriously? Picking up a cough differential of bronchitis vs. CHF? And yes, I’ve diagnosed Wegener’s. I’ve also correctly diagnosed metastatic liver CA, from the primary lung site…MISSED by THREE different physicians, including the patient’s gastroenterologist. Unfortunately, by the time he got to me, it was stage 4. He was buried TODAY after 9 months of heroic battle.

      So please, stop crying about the “70% of most common complaints.” Research shows we can manage about 90% of patient issues. Just like (gasp) family/internal medicine physicians. Who ALSO refer to specialists when needed. Funny thing…I refer LESS to specialists than my collaborating doc. I will collaborate with him…and I’m right on-track with my thought process and diagnosis almost 100% of the time.

      What’s really, really sad is that the blog is right. All we see in response, though, are the nay-sayers. NOT the physicians we work with EVERY DAY who value what we bring to the table.

      • logicaldoc

        Not kidding.
        #1—Good for you above with your isolated “case Studies”.
        #2—I work with Mid-Levels everyday and see what they miss.
        Good luck in your life.

        • kjindal

          not to mention the general clock-punch, union-benefits-obsessed mentality of such folks.
          Let’s face it, Harvard graduates are not aspiring to be midlevels, or somebody’s assistant. They have higher aspirations than that. It’s just a different caliber of professional entirely.

          • Cyndee Malowitz

            I suspect a Harvard grad isn’t going into primary care anyway.

          • kjindal

            that’s not true at all. medical schools (esp in the northeast and west coast) are filled w/ivy league grads, and many of them do become internists, pediatricians, family practice docs, psychiatrists, and ob/gyns. I am doubtful that nursing schools are attracting ivy league graduates. As an undergrad myself I didn’t hear ANYONE aspiring to go to nursing school.

          • Mengles

            Perfect phrase to describe Cyndee: “Always wrong but never in doubt”.

    • macbook

      Completely agree with you logicaldoc! I have no idea how in the world anyone could possibly compare medical school/residency to NP/PA training.

      We all work with them on a daily basis and know the facts….

  • Kaya5255

    Nurse Practitioners are nurses and physicians are physicians. NP’s have a role in healthcare, but not as the “lead dog”. Same to be said for PA’s. I have been seen by both mid-levels for routine services, but when I’m really ill ( and knock wood that hasn’t happened??!!) , I want MD tacked after the name.
    In my state the push by NP’s for independent practice has died in committee at least twice, that I’m aware of. I expect it will continue to happen in the future.
    I am sorry, and I mean no disrespect, but you can’t compare the level of training and clinical experience MD vs. NP. There is just no comparison.
    NP’s and PA’s are a part of the healthcare team and a valuable part of it.
    Physicians must be the point and show the direction. Mid-levels will just have to accept they must follow.

  • Adolfo E. Teran

    Dear Kim, I am glad you like to assume things about other professional’s training. I wonder why you do not like when others assume about NP’s training. If you are a caring professional and give excellent care to your patients, who cares what others think. If you are there for your patients, listen,examine and guide them the right way then that is the end of the discussion. You can be a jerk ,and you are jerk no matter what you do. I am a family doctor, I do not walk on water. I practice with a Pediatric NP, I respect her and we work as a team for the good of my patients.

    I think you as a professional have to value yourself, the quality as person and as provider will show. I think patient can smell it from miles away.

    So no worries, I do not have to compare with anyone, I am myself.

    My 1/2 cent, iMHO.

    Adolfo E. Teran

    “I like to joke that I did a thirty year “residency” before striking out on my own as an independent NP. I won’t even attempt to translate that into clinical hours , but I feel safe in assuming that most neurosurgeons have far fewer under their belts when they hang out their first shingle.”

  • Robert Bowman

    Family practice positions filled by MD, DO, NP, and PA are the only local or adjacent zip code or county located clinicians even in a position to impact most of the elderly, most who are being added to care, most who are not covered, and over 70% of the most rural or most underserved patients. Other sources specializing by child, young female adult, adult, or elderly have average distribution – failing most Americans in local or adjacent locations.

    US MD and non-citizen MD are 7% family practice position in result, DO is 17% family practice position, Caribbean is 25% family practice position, NP is 25% family practice position, and PA is 25% active family practice position result for a career. Family medicine is 90% family practice position result, but designs for medical school preparation and training and designs for GME and designs for reimbursement prevent family medicine choice – as in 3000 annual graduates now as in 1980.

    PA designs made permanent in family practice result are best solutions for producing the family practice needed as long as they keep 90% family practice position result like family medicine. FM accelerated designs with 1 or 2 years less preparation and training are as good as PA in cost for the yield of primary care visits. NP is slightly less but equivalent.

    Unfortunately the current 25% family practice result (33% active clinician for primary care) is dilute and has lower volume in a career due to shorter careers (36 for FM, 31 for PA, 24 for NP), less volume per FTE (60 – 75% of FM), and less activity (60 – 67% vs 85% for FM). These all reduce primary care visits and impact where needed.

    For most Americans, what matters is location location location. Only NP, PA, and FM graduates have the locations for most Americans in most need of workforce. If NP and PA make substantial numbers permanent to family practice, this segment should get support. If FM decides to dump preparation and 2 years of medical school not specific to FM, health access, teams, primary care, and clinician training, then this FM medical school should be the design for primary care – one that works for all ages, all locations, and all populations with less cost for training, less cost for distribution, and less cost for all of the reasons that people claim – but will not materialize because of location location location.

    Problem solving requires a specific solution – not current solutions and current associations and current institutions to benefit with most Americans remaining behind by design – worsening since 1980, worsening with 10 times more NP grads and 6 times more PA grads and less than half as much primary care from all sources per graduate, except the one permanent primary care source which has remained at 3000 annual graduates since 1980 – by design.

    More primary care visits per graduate (not 1/3 of 1980 levels), more primary care visits where needed, more primary care spending, and more health care spending where 65% of Americans reside in areas with multiple times less health spending – these are solutions for most Americans in health, economics, and more.

  • Robert Bowman

    Quality, especially for most Americans residing where concentrations of physicians are lower to lowest, is about social determinants, situations, and what has happened during 99% of the life of the patient, not the less than 1% of health care encounters. Child well being and what shapes this from the earliest months and years of life is the most important – especially for cost, quality, and access.

    Studies that demonstrate no difference include NP vs physician and teaching hospital work hours interventions. Health care is really about patients and their situations, especially where care is most needed.

    This is why pay for performance, value based, bigger is better, and readmission penalties fail along with studies that try to compare apples and oranges such as Critical Access hospitals with others with different funding, personnel, and mostly different patients.

    JAMA studies from Hong indicate pay for performance penalizing physicians who care for complex populations – as also seen in the top penalties going to 14% of rural hospitals where populations are most complex, 9% of rural hospitals overall, and 3% of urban hospitals.

    Penalizing care where needed, especially care provided mostly by family practice clinicians because of where they are located, sends even less health care dollars where health care and other dollars are least.

    Regardless of type of primary care clinician, 30% more primary care spending over the cost of delivering primary care is required for primary care recovery. In addition most of the nation needs 30 – 50% more spending at a minimum. Since the spending there is so little, this is not as much overall. The problem remains 1% of the land area with 10% of the population with over half of health care spending in just 1100 zip codes clustered together. This is where all lines of revenue and the most revenue in each line intersect – leaving all others behind, especially primary care and primary care where needed.

  • BudgetDoc.com

    Thanks for the great article, Kim!

    It’s heartening to see that, even in the midst of the debate, you have not forgotten the most important part of the profession. That the wellbeing of the patient, and not money or ego, is the true bottom line.

    • Kim Byars

      Thank you, BudgetDoc!

  • Anthony D

    “Apparently the Affordable Care Act has inspired panic among some
    physicians groups worthy of the fear historically reserved for deadly
    epidemics.”

    If you can use Google and do some basic research you will find out for
    yourself just how bad it is and come January 01 just how much worse it
    is going to get.

    But to get you started, a 2700 page bill backed by 13,000 pages – and
    climbing – cannot be good. Add in the IRS who is going to be handling
    the enforcement of ObamaCare….what could possibly go wrong!