Unify the standard to practice primary care

Unify the standard to practice primary care

An excerpt from The Demise of Medicine.

As with the Aesop fable, familiarity breeds contempt. The role and responsibilities of the physician are being slowly eroded by the media, the legal profession, and even other allied health professions. The tools we hone and more importantly the thought processes physicians develop to diagnose and treat are different than the tools nurses or any other medical paraprofessional use. Generally speaking they tend to learn through hands on application and algorithms whereas I learn through theory and an understanding of the basic science. This allows me to work through the problem and make a decision based not on the recommendations of an “expert” but on my own knowledge and logical thinking skills. After all, most “experts” do not have more formal training than I, just more experience. Also not every patient can be plugged into an algorithm. Not every patient is straightforward. I would venture to say that most patients are not straightforward and present unique circumstances that do not fit neatly into predetermined treatment plans.

This difference becomes glaringly obvious to me when I work with nurse practitioners (NPs), which is every day since my practice consists of six physicians and a nurse practitioner. Nurse practitioner training makes them think differently; with emphasis on prevention, education, and executing a patient care plan, not necessarily the diagnosis and treatment of a disease state.

Depending on the state in which they practice, nurse practitioners have varying levels of responsibility. In some states they function under the direct supervision of a physician and in other states they work independently. My overall experience with these “mid-level” providers is that the education and training is not comprehensive enough to properly evaluate and treat patients independently. This is dangerous.

Briefly, a nurse practitioner is a nurse who has completed her bachelor of nursing degree and has gone on to complete a post-graduate program, either a Masters or Doctorate degree. The program focuses on the nursing model, which emphasizes holistic medicine, preventative care, and patient advocacy. Unfortunately, my job as a primary care provider encompasses not only that but significantly more. Let’s refer back to the car analogy for a minute. My concern lies in basic sciences and pathophysiology.  A physician is trained in the art of understanding why things are happening, generating a list of possibilities (called a differential diagnosis) and treating based upon this list. A NP is presented with common scenarios and is expected to learn treatment algorithms without necessarily understanding the nuances of why they are doing what they are doing. They may know that for a patient with medical condition “x” they treat that with medication “y” but they do not understand what, on the cellular level, is happening.

The American Academy of Family Physicians describes the difference this way:

Due to his/her seven years of medical and clinical training, a family physician can provide all the services of a nurse practitioner. But more importantly, the family physician brings a broader and deeper expertise to the diagnosis and treatment of all health problems, ranging from strep throat to chronic obstructive pulmonary disease, from unsightly moles to cancer, from stress headaches to refractory multiple sclerosis. The family physician is trained to provide complex differential diagnosis, develop a treatment plan that addresses the multiple organ systems, and order and interpret tests within the context of the patient’s overall health condition … Nurse practitioners are trained to recognize and treat common health problems, such as strep throat, ear infections and conjunctivitis. They are trained to monitor specific chronic conditions such as hypertension, high cholesterol, and high or low blood sugar problems. They provide preventive care such as immunizations. They educate patients about chronic conditions, medications, nutrition and exercise. They refer patients to the family physician when a patient has multiple symptoms that may or may not be related, a condition that is not specific to the nurse practitioner’s training or a condition that has multi-organ effects and/or requires multiple medical interventions or medications. The nurse practitioner is trained to recognize and treat the three or four most likely causes of a patient’s symptoms.

This may seem unnecessary and overly cautious if you are the one trying to fill the primary care shortage that is expected in the years to come, but if you are the ill individual whose life depends on the nurse practitioner’s ability to properly treat you and your specific situation, I would think that that difference would be very important. Unfortunately not everything fits into an algorithm and not all problems present in a classic, or “textbook” way.

In my office we have a meeting with the office management and providers on Friday. It is during that time we discuss issues, both administrative and clinical. Very recently my fellow physician brings up a topic of concern to the meeting. He passes out copies of a “wellness physical” that a patient of his had just received from a nurse practitioner at the local pharmacy clinic. This “physical” discussed smoking status, weight and exercise options, most recent cholesterol readings, his need for colon cancer screening, a discussion of healthy lifestyle choices, and he received his flu shot while there.

It failed to address or mention at all any of the chronic disease states that this individual had. It failed to mention any past medical history (“none” was entered into that block) or acknowledge that this person was on multiple medications. It failed to take into account his cardiac risk factors or family history. It failed to address his uncontrolled blood pressure that he had at the time of the “physical.” Had the patient followed the wellness guidelines as presented without taking into account his cardiac risk factors or his currently uncontrolled medical problems, he could have very well ended up dead of a heart attack or stroke.

This nurse practitioner was given the authority to “diagnose” and treat illness, or in this case perform a wellness examination, without being given the proper tools to do so. In my opinion to make the statement that a nurse practitioner working at the corner pharmacy “clinic” who has had probably six years of education at a level that is of significantly less detail than mine has the same basic fund of knowledge and therefore the same authority to practice medicine as I do after eleven years of education, is tragic and dangerous. This misfortune is self-perpetuated in the hubris of the nurse practitioner programs. They seemingly do not know what they do not know and self-regulate themselves by having separate certification examinations.

It is my opinion that to practice medicine at the same level of a primary care physician, they should be held to the same standard. My recommendation would be to simply have all primary care providers with the same level of responsibility and authority, which may include physician’s assistants in some states, take the same certification examination across the board regardless of educational background. This would ensure that all providers be able to “function” at the same level of competency.

Ironically this would probably mean “dummying-down” physician certification examinations, but at least we would know roughly where the bare minimum of education lies. When I talk to a nurse practitioner that I do not know on the phone, I really have no basis to know that she even understands what she is talking about. Many times she cannot tell me what else is on her differential diagnosis or what else she could do to further rule in our out other potentially life threatening conditions, or even what the other possibilities are.

Before we get out the torches and pitchforks, let’s think about this for a minute. Of course there are multiple instances where physicians do dumb stuff too. I’ve seen it firsthand. I’ve probably done some of it. Being able to regurgitate information doesn’t make someone a good doctor. There has to have insight and common sense also. I get that, but if the fund of knowledge is not there at the front end then it will never be there after the fact.

Andrew Morton is a physician and the author of The Demise of Medicine.

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  • SB Doc

    Let them take the Family Medicine Board exam. The FM board exam is straight forward, is bread and butter and requires that the examinee stay up to date with current medical practice.

    • Dr. Drake Ramoray

      While that may work from a credentialing standpoint. What schlub is going to go through all the trials and debt of medical school to sit for the same certification exam. Might as well just remove family practice as a specialty then.

      • Suzi Q 38

        My point exactly.
        There would be certain, very bright individuals who were excellent test takers that could pass the exam.
        If they pass, then give them the MD title.

    • Suzi Q 38

      “The ship has already sailed.”
      They do not have to take the FMB exam.
      They have their own board exams.
      This is why they are called Nurse Practitioners and Physician Assistants instead of doctors.
      If they had to take that exam, and for whatever reason passed it without going to med school, then make them MD’s.


    This discussion is moot until you unify your own primary care programs. Missouri is going to have an “assistant physician”, Texas and California are willing to shorten training if you will stay in those states and practice. All of your major organizations are scrambling to “revamp” primary care training to “better fit” today’s environment. Medical educational programs all over our country are laboring over how to shorten and “streamline” programs to hopefully find more students who are interested in primary care. You can’t even fill all of your residency slots. Some students would rather sit it out and wait another year instead of taking a primary care slot. Meanwhile, back at the ranch, NPs like me have booming private primary care practices with more than they can handle. I treat everything you treat in your clinic and I bet I do more. Please quit whining about me and my profession and get a grip on your own profession. This post is so “when you have nothing else to say, call them names” flavored. I prefer posts like this because patients of NPs see them and think, “I wouldn’t trade my NP for this guy if he moved in next door.” The more you hate us, the more we will prosper. Now hate is a strong word – but it is obvious from the degrading things you say here that you have nothing but contempt for us. All of the usual posters here – deceased, buzz, nquiem, stevecaley, PCPMD, etc., pleas don’t take offense to my post. I am responding to the OP only. I greatly respect you guys and would work with you, beside you, or for you any day.

    • PrimaryCareDoc

      I agree that we’ve got to police our own profession. This “assistant physician” idea is one of the stupidest things I’ve heard in a LONG time. And that’s saying something, given all the dumb ideas that non-clinical people come up with.

  • Dr. Drake Ramoray

    I think you should seriously consider Chili Cheese Fritos as your vice of choice, a much more complex flavor profile and your hands won’t get stained with the redness between patients.

    • Suzi Q 38

      My “vice” of choice are Oreos.

      • RuralEMdoc

        Ok, take your vice and then dip them in peanut butter. You can thank me later

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

    While you guys are debating and splitting hairs here, the issue is being settled on the ground. The $4 “primary care” visit is coming to a Walmart near you: http://www.advisory.com/daily-briefing/blog/2014/08/health-care-for-walmart-launches-primary-care-clinics-in-south-carolina

    Health care for the poor does not include family doctors, and soon will not include NPs either.

    • NPPCP

      That is crazy!!! Trying to think it through. $40 bucks has to be for basic care. No way someone with 2-3 chronic issues can be seen for that in any setting. Its the TRUE retail price. High volume, low cost = profit. I cant wait to see how all of this washes out. It will be interesting. In any case, people like this author have completely poisoned the well. There is really nothing left to say about the topic. The disparaging remarks in the posts and comments cannot go any lower. We are all at the pitiful bottom. In the meantime, the big boys are carefully planning to clean up. Better get your bills paid off Andrew.

      • Dr. Drake Ramoray

        Nah, they charge 40 bucks for the visit. Lose money on bringing them in, but then make money on the pharmacy side, the supplement side (Cinnamon for DM etc.). Maybe some slim fast or other weight loss products. Perhaps sell some Dr. Scholl’s shoe inserts, or simply cold medicine. IF they make enough on the retail side, they can take a hit on the healthcare visit side. Just bring em in, the increased foot traffic will up their revenue for the store. Of course selling anything like this in your office is illegal.

        I’m sure if they turn out to be complicated they will send them to you or me.

  • Suzi Q 38

    The NP and PA’s are here to stay.
    Good luck trying to turn back the “clock” and getting rid of their jobs.
    The ACA has figured out that less physicians want to become GPs or FPs.
    With the expected shortage, there will be solutions.
    This coming in the form of NPs and PAs.
    Besides, there are some really bad and jaded doctors out there, and conversely, there are some PAs and NP’s who do a very good job.

    It depends who is examining me.

  • Shirie Leng, MD

    Wow. A lot of negativity going on here. I think Dr. Morton doth protest a little too much. Primary care patient encounters are often about common and non-life-threatening illnesses and follow-up visits for medication management. For some of those simple things, you really don’t need 10 years of school. Let the NP’s do the simple stuff and use that MD you have to throw your 12-point differential at the difficult stuff. If you don’t like what your NP is doing, maybe the problem is your NP, not all NPs. I’m with buzz on this one. Let’s work together.

  • Dr. Drake Ramoray

    Everyone knows the ABC’s of anethesia:


    Harsh, perhaps but I heard the joke originally from my anesthesia attending while i was a medical student.

    • Shirie Leng, MD

      You’re just jealous.

      • RuralEMdoc

        Honestly, so jealous…….

        Also, your patients never have full stomach’s, mine always do.


        It gets on my shoes.


    Yes Yes – we know. It’s all been covered. Nothing changes.


    You just can’t stop – so bitter. In my clinic I take care of a neurosurgeon and his entire family, two state legislators and their families, and all of the elected officials in our city. There are 5 physician clinics within 10 miles. Your one liners just aren’t true. I know you wish they were – but in real America, they aren’t. Everyone sees this and sees your bitterness. Please discuss with kindness and honesty. Please.

  • RenegadeRN

    Wow!…just..wow. The vitriol coming across in your article is palpable. Please just get over yourself.
    By the way, noticed this directed 99% at nurse practitioners, and one TINY mention of physicians assistants. Is that because you feel they are comfortably and firmly placed under your thumb and NPs less so?

    Agree with Buzz, just divvy up according to strengths, move on and quit your whining.

  • Shirie Leng, MD

    CRNAs can take my simple cases any time. They are well-trained. There’s no reason I need to personally do straightforward cases with healthy patients. I know PC is not easy. But some parts are. Just like in my job.

  • RuralEMdoc

    So you want your day to be filled with only complicated level 5 patients scheduled for 15 minutes, sounds like burnout city.

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