Interesting collection of comments at allnurses: Is an nurse practitioner (NP) also a physician?
Says one reader over at allnurses.com. As I've said before, the idea that nurses can "take over" primary care is all dependent on how you define primary care. I have no doubt in my mind that how the NP agenda defines primary care is far different than how I define it. Primary care, the way I practice it in a hospital setting can't be practiced by NPs independently. There are certain aspects of my job that a monkey could do. That a secretary could do. That a nurses aid could do. That a nurse could do. That a nurse practitioner could do. But none of them can do everything I do as an entire package. Just as I can practice cardiology form a hospitalist point of view, I would never claim to be a cardiologist in the same scope a cardiologist practices.
I know this because I have lived through the training necessary to practice hospitalist medicine independently. I have lived through the training required to practice outpatient comprehensive primary care independently. I have had NPs train through Happy's Hospital rotation. I speak with NPs (and PA's for that matter) at 3 am who transfer me patient after patient from rural America with terrible ED work ups, stabilization and management skills. Work ups that lack basic medicine skills.
And I can say categorically, without a doubt that primary care as practiced by myself is not the same as primary care practiced by those less trained.
So define primary care as you may. As a patient, many may never know how to differentiate the care they are receiving from the care they need. Many are happy not knowing otherwise. I can say only that knowing what I know about the training involved in both, I would take a newly minted graduate of internal medicine opportunities, one week out of residency to be my primary care doctor over a 30 year practicing nurse practitioner every single time. That's not because nurse practitioners are bad. It's just that my idea of primary care is far different than what the nursing profession has to offer.
And I can say that with a straight face, every single time.
"I am just wondering because I was reading this article in Reader's Digest about how a lot of people are switching over to using NPs for their care. The article quoted a patient saying, "my NP is my physician."
ReplyDeleteYou are kidding right? You wrote a whole post on someone who read something in Readers Digest? OK, I'll bite. Happy it seems you have no love for NP's, which is fine. But from reading your previous posts, you believe money makes the medical world go round. So, what is more cost effective, NP's or Primary MD's? Are their patient outcome data vastly different? I honestly do not know. If NP's are causing poor outcomes and increased costs, then let's fire them and hire those monkeys you seem so fond of.
NP arent doctors, in my country Nurses just administrer drugs.
ReplyDeleteIn my experience, most rural hospitals are very small without alot of techology or staff. A rural community may only have ten doctors in the county! We were discharging a patient who needed a PMD. There was 5 doctors within 30miles of this not very small county. And this town had a hospital! So if you can imagine, there may be a doctor (NP or PA)moonlighting in the ER. They probably have 20 or so people in the hospital, and 10 people needing stiches, casts, asthma treatments...etc...
ReplyDeleteI would imagine that if there was more than 3 critical people, they would start sending them out, no matter how talented the provider.
I am sure many of these rural ERs do not have enough equipment to handle all of the critical care. They may not even have Ct.
I think any PA of NP who transfers a critical patient to a bigger hospital is doing their job!
I am sure alot of the stuff that comes into a rural ER a midlevel can handle.
Okay...wait another example. A live between two decent size cities. The smaller city has one hospital that serves about 100,000.
ReplyDeleteIt's ER probably staffs 2 docs, and two midlevels at night. That is not that many providers working the hospital in the middle of the night. And it is a hospital with a 100 bed psy unit and OB on top of it all.
"The issue would be evaluating the safety of a cardioversion to return to sinus rhythm (not an emergent cardioversion for RVR/low BP unresponsive to cardizem/beta blockers/dig etc)---sometimes when you do this, you send a huge clot to the patient's brain if you're not careful"
ReplyDeleteim very aware of that.
I avoid cardioversion as much as i can, but when the patient is too unestable, you have to do it whether or not you like it, or go with him on the ambulance to see how much he/she can last.
Duhr, not all cases of ARF need dialysis, but you'll feel like a huge ass if your patient has EKG changes in the middle of the night in BFE and that K is suddenly 6.5 or 7.0 Not even a big hospital will dialyse patients at night for the most part. I'd even sue over that shnit. "You knew her creat was 8.0 and BUN was 200, but you elected to not have her near a dialysis center. Why?"
i wont argue that one, a patient which such condiction is a patient that need to be in a big hospital, but not all the ARF have that progression, and and those are criteria of dialisis, im talking about the patient with creatinine of 2 with postobstructive renal condicion that gets better with a foley, or the one who is severely dehidrated with relative low creatinin levels.
is my english that bad, by your tone seems to be horrible, I apologize i havent been outside my country to practice it properly.
ReplyDeleteon the other hand i would try to change that reality as much as i can, once i get back from spain with my speciality. we have many political problems with our current president that health system is no longer a concern of our society.
"How do you measure outcomes of bad medical care being saved by good care?"
ReplyDeleteDear Savior,
It is relatively easy to measure any outcomes. If you feel care is compromised at the rural hospital that is referring to you, then document and trend it. A random lack of an IV is not a trend, although I am sure it remains in your memory more than the good care that occurs by the NP's in rural hospital.
you don't understand what I'm talking about most of the time. Chavez is tricking elections over and over. we are fighting every day but is not easy to get rid of someone that buy the concience of many people with money, he dont have acceptance of anyone still try to show the world an many Venezuelans he is savior.
ReplyDeleteYou need to go to allnurses for blog fodder? Wow.
ReplyDeleteAs a PA who works in a large academic center, and also moonlights in a small rural ER with no physician in the ED, I feel compelled to make a couple of comments..
ReplyDelete1. My issue with the comments on allnurses would revolve more around the concept of "absolute equality". I am a PA, capable of much, highly educated, and equivalent to a second year EM resident at the end of their second year, or a third year resident in the first six months of their third year. Can I practice primary care? With some additional experience, certainly. (EM is different in many aspects from primary care) Does this mean I am an absolute equal to a physician? For some conditions, yes, but not ALL situations or conditions, and any NP or PA who thinks otherwise is only fooling themselves.
2. IN the rural ER, if someone codes......I am not calling 911, I am working on the patient. It's happened. I also have run codes at the academic place I work at. There is an additional caveat for the smaller ER. BECAUSE there is no physician there, they require a minimum of 5 years experience prior to working there. I can manage almost everything, as I've said probably (at least at this point in my career) 85-90% of what comes through the ED doors on my own.
BTW- Happy, I get referrals from more friggin Primary Care MD's who are requesting Ortho, or Optho, or ENT eval. Some of them don't need it. I have had at least three primary care MD's send scathing letters to me regarding why I, the PA, chose not to follow their wishes. Thankfully, my department backs me up. Sometimes I wonder if they even examined the patient. Granted this doesn't happen "all the time", but it happens.
THE point is, you have to evaluate EVERY individual provider, individually. I have a friend who is an infectious disease PA in Wisconsin. He is also smarter than any MD or DO I have ever met, and may be the smartest person overall I have ever met.
Another one is a PA, who is considered one of the top complicated headache experts in the entire country. He has patients referred directly to him from neurologists for further evaluation.
IS every PA like this....certainly not, but there are substantial, SUBSTANTIAL differences in schooling between NP's and PA's. As well as differences in licensure, CME requirements, and general outlook.
Please refrain from "lumping" us together, as we are separate professions.
I like how you seem to think primary care doctors can handle everything.
ReplyDeleteI have stable GERD, asthma, and diabetes. I've been on the same exact meds for 5 years. My last a1c was 5.9%.
Yet my PCP won't prescribe my insulin- she doesn't feel comfortable with insulin pumps- so I see an endocrinologist.
And my PCP won't prescribe my Prevacid. She doesn't feel comfortable with BID dosing on it. So I have to see a GI doctor.
And my PCP referred me to a dermatologist for my acne that didn't go away after a week on Differin.
And then my opthalmologist that the endocrinologist referred me to caught papilledema that was from the tetracycline that the dermatologist prescribed that bought me a referral to a neuro-oncologist.
In short, I'm a largely HEALTHY 23 year old that has seen, since HS graduation a gyn, endocrinologist, dentist, gastroenterologist, ophthalmologist, allergist, neurologist, dermatologist, oral surgeon, and, oh yeah, my "comprehensive care physician."
I just thought I'd jump in here with an outsider's opinion. I'm a different kind of "Dr" (PhD in astrophysics). I'm also married to a Nurse Practitioner, to whom I would happily entrust my primary care over most physicians that I know.
ReplyDeleteWhile I am well aware that many NPs are not "fully qualified" to be primary care providers, I would submit that neither are many MDs. I would further assert that, from my experience, what many NPs lack in training, they often make up for in diligence and compassion, making them preferable by far as providers than a well-trained but apathetic physician who thinks himself (or herself) superior to the task at hand (not meant to be a blanket condemnation, but rather a description of certain individuals I've encountered).
But that is not the point I wanted to make. It seems to me that much of your argument depends heavily on an erroneous definition of the term primary care. You speak frequently of inpatient primary care, and I would submit that there is no such thing. Once a patient has been admitted to the hospital, they are no longer undergoing primary care. An inpatient is, at the very least, undergoing secondary, if not tertiary, care. As a hospitalist, you are not a primary care physician. By definition, primary care represents the first contact of a patient with the health care system, and one of the most important characteristics of a good primary care provider is knowing when a patient's condition is beyond his/her scope, and it is necessary to refer them on to the second tier of health care.
As a doorway to the health care system, different primary care providers may be able to handle a wider or narrower scope of care, and thus one provider may be comfortable handling patients that another would choose to refer to a specialist. As a rule, I would expect an NP or PA to have a lower threshold of acuity for referring patients than a DO or an MD, and I think that is entirely appropriate. It should be viewed not as a weakness of the practitioner, but rather as a strength in the recognition and acknowledgement of their own limitations.
As MDs have abandoned the field of primary care in favor of more challenging (and lucrative) specialties, mid-level practitioners have moved in to fill the gap that they have left. In doing so, they have provided an efficient and cost-effective alternative, for which they should be applauded, not vilified.