From the comments section:
Nursing education and residency programs receive NO Medicare funding at all. Therefore, the idea that NPs could self fund for 12000 hours of training is ludicrous.
I have the academic background which would have allowed me to go to medical school, had I chosen it. However, I did not want to come out the other side bitter at having spent the best of my youth in a hospital working 80-100 hours a week. More than that I did not want to develop the attitude demonstrated by many MDs on this blog and of too many other MDs: arrogant disregard for the contributions, methods and experiences of others--be they nurses, other MDs, their own spouses, and oh, yes, what about those patients....
The argument that patient satisfaction was higher because NPs listen more than MDs is an intriguing argument about the value they bring to the table. If in fact that was the end goal of delivering health care, to make the patient happier, than may I suggest we begin a new educational tract in learning, available in community colleges all acros this country. We can call it an associates degree in listening. You can obtain your degree in as little as 12 weeks with hard work, doing your homework, and listening to the instructor. Once complete, we will then open millions upon millions of listening centers where patients, no matter how sick, or how healthy can go and just have somebody to talk to. Patient satisfaction scores would soar to the Heavens. At 1/10 the cost.
The idea that education and listening leads to great satisfaction scores is all great and dandy. Until the patient comes in with a platelet count of 12K and jaundice. All the education and listening in the world won't help the patient survive this rapidly deadly illness if you don't know your differential diagnosis. No education or listening in the world will save a patients life if the education required to understand the disease process has been missed. And that education does not come at the hands of a nursing degree and 1000 hours of clinical experience. I know this because I completed four years of medical school and three years of residency training working over 80 hours a week.
It's a hard patient? Just refer them on. That seems to be what you are saying. Send them to someone who knows what they are doing. Like a comprehensive care doctor. Maybe that's your position. You'll have to clarify it for me. That sounds reasonable, but it also leaves holes to the argument, based on your research presented, that extenders are equivalent to comprehensive care doctors. I can assure you based on your training there is a lot of stuff you don't know that your comprehensive care comrades do. Vast oceans of information which become important on a daily basis.
The vast expanse of disease and illness that is internal medicine cannot possibly be understood with a decreasing expectation of our educational system. Talk of going to 56 hours a week medical residency is just ludicrous. In your own words you stated you had no intention of working extremely hard in the "best of my youth." I need to say no more. You have presented your position for all the world to see.
Take a look sometime at the bible of internal medicine. Harrisons. It's over 1200 pages of small fine print. That is what a practicing internist is expected to know. To save the lives of patients who need them when all Hell breaks loose. And then incorporating those 1200 pages of single disease descriptions into a patient care plan where every disease is intertwined. You can' learn that from a book, nor from a 1000 hour residency. That's why I entered residency a boy and came out a man (I know, it sounds cheesy, but it's true.)
Like most other fields, medicine is an 80/20 phenomenon. Eighty percent of what I do is the same thing over and over and over again. I could spend 80% of what I do on just managing 10 medical conditions and becoming really good at it. It's the same with specialists. For me to call myself a pulmonologist or a cardiologist or a gastroenterologist would be simply ludicrous. They spend three extra years of training to master the 20% that I never deal with, but 80% of their practice could be managed, in all likelyhood with the same 10 condition phenomenon that I deal with. I don't refer every pneumonia patient or afib patient or CHF patient or abdominal patient or hepatitis patient to to a specialist . Nor would I expect every NP or PA to refer every case of diabetes or HTN to an MD. There is a roll in patient care for everyone. Which is great. But your position that you are equal, if not better than an MD is concerning.
Correct me if I'm wrong, but you seem, from your evidence presented, to believe that NPs are on equal standing with comprehensive care physicians. I'm here to tell you you aren't. Sorry. You have your role in patient care, just as I do, just as the pulmonologist does. And just as I don't equal a pulmonolgist, you don't equal a comprehensive care doc. Please don't be offended. Just understand that your training is different and unfortunately lacks the necessary components required for MD certification.
Residency prepares you very well for the 80%. But it's the other 20% that you can't get training on anywhere else on this earth, except in your medical residency level training. And it's the 20% of your 80% that don't follow the text book that requires 12,000 hours of training to know what to do. If you don't understand the difference between you and me, I can't make you understand it.
Your stance that NPs are equivalent to MDs, based on a study indicating similar outcomes in an outpatient clinical practice, is frightening . I would fear for my life if managed by an extender who felt the same. Because I have experienced the training required to become an MD, I know what I know and I know what I don't know, as well as what you don't know, because I have also trained extenders quite close to the end of their training. Knowing what I don't know is so often far more important than what I know. If you believe you are equivalent to MDs I fear for your patients. If in fact that was the case, we should disband internal medicine opportunities, family practice and pediatrics as inefficient models of patient care. Is that what you suggest?
I didn't go to medical school to make patients happy. Nor is it my job to make patients happy. If they want to be happy, they should go to a comedy club. I went to medical school to diagnose and manage disease. I have a great bed side manner that will often bring joy to patients during their time of illness in the hospital. But my driving goal is not for them to leave with a smile on their face and say Dr Happy made me happy. My goal is for them to leave the hospital with less illness than they came in with, if it's possible. And if they leave happy, so be it.
I have one question for you anon. Your position appears to me to be that you are equivalent to comprehensive care doctors, if not better because of your ability to educate and listen and higher patient satisfaction scores with no change in quality.
What does the comprehensive care doctor bring to the table that you don't? That's my only question.
Regardless of what you might think, listening is important. If the MD won't take 3 minutes to listen to symptoms, then it doesn't matter how smart he/she is, does it? I left an MD for an NP, and since the NP listened, I finally got a diagnosis and treatment. Certainly the MD was smart enough to diagnose me, but he had to listen first, and he wouldn't do that.
ReplyDeleteFucking A, Happy. If you would drink at the well of knowledge drink deeply for a little knowledge is a dangerous thing. That's the problem with the mid-levels...many of them don't know enough to know what they don't know.
ReplyDeleteanon 12:54 - HH never said listening wasn't important, just that it's not enough by itself. MDs should/must listen, and many are not trained as well as the NPs in this, and certainly could improve. So, how would you answer HHs question - What does the doc bring to the patient that the NP doesn't?
ReplyDeleteIt still comes back to the question of equality. While we are not equal in training or knowledge we each have our strengths. Why not embrace both professions for what they bring to health care? The constant arguing for superiority is unbecoming! The private practice I work for is a rare one that accepts Medicaid patients. We can only do this because we have nurse practitioners willing to work for less than the physicians and committed to caring for these patients. The physicians who refuse to take Medicaid patients and forgoing primary care are fueling the rise of NPs!
ReplyDeleteAs I wrote elsewhere in your blog:
I'm an NP in practice for five years working in nursing homes and a geriatric oriented primary care clinic. I am grateful to have wonderful physicians in the practice to ask for help, and they are grateful to have me to do a truckload of work for a lower salary than they receive. Why anyone would think nurse practitioners are the same as physicians is the question here. Just because some physicians are threatened by nurses having an option to work for an advanced degree doesn't mean the DNPs think they are the same as a physician. It is not logical to berate NPs for having less education than physicians and then to berate them for trying to become better educated. Fortunately for me I was allowed to continue to train on the job after my degree and learned from my physician employers and NP fellow employees. I am still not the same as a physician, I'm a nurse! The physicians also believe I know some things as a nurse that they weren't taught. Show a little respect for each other and see what each profession brings to health care.
I respect the nursing profession, when they are nurses. But when a nurse becomes an NP, or DNP and crosses into the realm of medicine they are no longer practicing nursing but medicine. As a medical practitioner their skills, training, and clinical knowledge is third rate. Why should they be embraced as professional colleagues?
ReplyDeleteWe once had a gold standard know as the physician. When you were sick you would see a physician sooner or later and you knew what that training stood for. Now, we have created a two tiered system. If you have money you get a physician, if you don't you have the misfortune of an. That's when you hope you get the one that is "just as good as the worst MD" as the party line goes. NP's and PA's have caused our medical system to regress in quality.
Kaiser Permanente has laid off many of their FNP's because they realized they referred too often and were more costly than a primary care doc.
Anyone that thinks that an NP or PA is completely equivalent to an MD is an idiot. But that's not to say that I haven't worked with MANY MD's that were incompetent and absolutely terrifying in their ignorance. You genuinely wonder how in hell they got through Med school and residency. I've worked with many NP's (my husband included) that I would much rather trust with my patients than some of my MD colleagues. To say that you hope that you get an NP "just as good as the worst MD" is asinine. Just because you're an MD doesn't mean that you're better able to care for patients than midlevels. In general, yes, but in practice there are some horrendous MD's out there that I wouldn't trust to take care of my parakeet. I think it's more productive to try to work together as colleagues rather than have this "I'm better than you" mentality. MD's and NP's and PA's aren't interchangeable and all of the ones I've worked with know this and don't pretend that they're doctors; they work in conjunction with the MD's. And they can be a lifesaver if you know enough to appreciate and use them.
ReplyDeleteOf course this devolves into calling doctors arrogant if we believe that our training better qualifies us than NP's and PA's. Here's a newsflash for those taking that stance. You can respect a person and the job they do while still being honest about job qualifications and training.
ReplyDeleteThis all sounds like a good argument for socializing medical -education- instead of medical care.
ReplyDeleteAs information technology improves, things like "differential diagnoses" will be easily solved with an Expert System and decent observation/reading skills, maybe some kind of clever way of displaying information.
The things that are difficult to replace with technology are physical assessment skills and establishment of therapeutic relationships.
The institution of Medicine is certainly full of rich history, brilliant minds and lives devoted to service and sacrifice, but things are obviously very different now than they were in the past, and the rate of change is accelerating. New roles are constantly appearing..old roles are shifting, and through all of it we're tasked with figuring out how to do the best we can for as many people as we can, yeah?
Obviously NPs aren't "equal" to MDs. Neither are PharmDs, Doctors of History or electricians. That's not the issue. Let us take that 80 off your hands, play with that 20, isn't that what you'd want anyway? To do and perfect the things that ONLY you can do? There are problems with how to pull that off, as you said, but just like your argument that the government is bad at running things therefore it should stay out of healthcare (i.e. the VA)...it's a stronger argument for making that thing better than it is for hoping the problem will be solved by wealth concentration. No provider is an island, our abilities are complimentary, not competitive.
What really irks me is that every day during a five day rotation of work as a hospitalist, I see physicians, especially subspecialists, relinquishing more duties and authority to NPs and PAs. If we continue this approach to the practice of medicine, then the distinction between the professions becomes difficult to see for the average patient and the general public at large. We physicians have nobody to blame for this but ourselves. We could rectify this if we wanted. We could stop using NPs and PAs and go in and actually talk with a patient and personally perform the history and physicals. In other words, we could practice medicine. But, many physicians cannot resist the temptation of rushing into a room, barely saying hello and then running to grab a chart to scribble a few words and a signature.
ReplyDeleteBeing a doctor is not easier, you learn everyday as a doctor, not just in collegue or residency even if you get 40 years of experience you still learn so does a nurse, the harder you study the harder you train, the better it gets, thats a law when it comes to learning, you get good on diagnosing a disease by seeing lots of cases. Who will deal a heartattack better someone who has seen it adn treat it 100 times or someone that has seen it 10 times, thats what we call experience mixed with studies becomes wisdom. there are bad doctors and good doctors,bad nurses and good nurses generalizations are bad. still i think that in order to treat and diagnose a patient you need extensive knowlegde trought years of learning and studying im starting to realize how ignorant is to believe we know everything, we tend to avoid diagnosis of disease we dont know, so basically to be a good diagnostician you need to cover among all specialities which is nearly imposible, thats why medical carreer tends to be so demanding in time, demanding on analazing skills, those who work for healthcare (doctors and nurses) must know that you are not ripping off your future by stuying and, if you really think you are sacrificing you future by studing meds, is better to choose another career, maybe im getting off topic but medical understanding on illnesses is not something that has to be handle with halved information, if you want to be good at something you need to work hard for it. doing your best sorry for the grammar im not english not even live on the states.
ReplyDelete"What really irks me is that every day during a five day rotation of work as a hospitalist, I see physicians, especially subspecialists, relinquishing more duties and authority to NPs and PAs. If we continue this approach to the practice of medicine, then the distinction between the professions becomes difficult to see for the average patient and the general public at large."
ReplyDeleteDude, it's not just you. Nursing is going through the same thing. Lots of things that RNs used to do exclusively are now done by CNAs, respiratory therapists, physical therapists, EKG techs, you name it. In some states you can even -administer medication- without a nursing license, as long as it's to someone who's developmentally disabled.
We're all going through this identity crisis because there are too many people who need health care services and not enough people to deliver them.
pm-rn stated:
ReplyDelete"We're all going through this identity crisis because there are too many people who need health care services and not enough people to deliver them."
It is not completely true that more providers are needed. I see similarly situated subspecialists using and not using mid-level providers. Those that use them simply do not want to document. It is not the case that the mid-levels are actually needed. It is a matter of convenience.
Further, I find myself preferring the subspecialists that do not use mid-levels. The mid-level intermediaries often do not add anything and sometimes muddy the water. In addition, they often are simply performing clerical duties. Physicians could do themselves a financial favor by substituting secretaries or scribes.
In regards to nursing, I often find the obsession with documentation (imposed by the Joint Commission, Medicare, and my fellow members of the bar) keeps the RN at the computer typing in notes instead of actually nursing. As a result, many of the other ancillary providers listed become necessary. Lessening the documentation burden would lessen the need for said ancillary providers.
I do not even compare NPs and MDs. Their models differ. One is not better than the other. The schooling - minus the residency - is nearly equivalent in terms of time spent. The problem is that NPs don't get a long enough residency. If you take a NP and a MD, both with 20 years clinical experience, the MD does not know more than the NP. Sure, he had a few extra classes 20 years ago - which he does not remember - but that's about it.
ReplyDeleteNPs are not trying to steal MDs meal tickets, they are attempting to better serve patients. Research has shown irrefutable proof that patient satisfaction and outcomes are just as high, if not higher in certain cases, when being treated by a NP rather than a MD. Some of this data is no doubt skewed because many MDs are so overwhelmed with patient loads that they simply cannot spend the time to provide competent care, but I see that as the fault of the MD for taking on too much.
Finally, I laughed when I read that comment about "once there was a gold standard - the physician." That was no doubt true. Unfortunately, it's not NPs that tarnished that reputation. It's the fact that nearly 60% of practicing MDs got their degrees in unknown schools in Pakistan, in India, in China. Then they did residency in the U.S. Then you have the American MDs who went to some Caribbean university. MDs straight out of reputable schools like Duke or Harvard or Wash U are rare.
Very soon, the idea that NPs are somehow "less" than MDs will change. A doctor is a learned person, and MDs are simply doctors of medicine. Eventually, when the Board of Healing Arts collapses in its ridiculous battles to slow NP progress, only patients will benefit. And NPs will no longer be asked, "Damn, you spent more time in school than a doctor. Why didn't you go to med school?"