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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