An Internist Offers Far More Than Primary Care

An internist offers far more than primary care.  A reader over at A Nurse Practitioner's View responded to a post by author Stephan Ferrara, NP. A post which does not represent my views at all. In response to Stephan, a reader leaves the following comment

Jane Know said...

Wow, how condescending is he? Yet, I do agree with the Happy Hospitalist that a medical education is superior to nurse practitioner programs. I don't know who would dispute that. But he's forgetting that most NPs have been in the real world practicing as nurses for several years, too. That real world experience counts for something that you can't learn in a medical textbook in school. Further, NP programs have pretty rigorous academic standards themselves, these days. Anyway, once we are all out there practicing as MDs and NPs in primary care settings, we are on pretty even playing fields. I know incompetent doctors and superior NPs. That is not a generalization about either profession, just a statement that sometimes the best education is on-the-job, and also variable depending on the individual. To me, it seems like the Happy Hospitalists may be focusing a bit too much on the status of MDs, and not as much on solving real world problems like primary care provider shortages and health care costs for people who can't afford doctors.

June 18, 2009 5:54 PM

I would have to respectfully disagree with most of these assertions.

1. Being a nurse for 50 years will not prepare you to practice a full scope of medical practice. The nursing career and responsibilities are simply not the same. I could be a doctor for 50 years and have no ability to practice nursing independently, even though I am around nurses in their capacity all day long. The two career pathways are not interchangeable. Nursing education and nursing experience does not prepare one to meet the requirements to practice independently in the same scope as an MD. If that was the case, we should all abandon medical school in favor of nursing school and nursing experience.
   
2. NP programs have rigorous standards. That's great to know. Now I ask you to put those standards up against any medical school and you will find that the two simply don't compare. It's not even close. In fact, if you knew how less rigorous your training was compared to any MD degree, you would be frightened at how under educated you would be to provide a full scope of care equivalent to your MD trained counterparts. Perhaps you feel MD training over qualifies one for the role you see yourself providing in the primary care world, independently. I might suggest you have a vastly inferior scope of practice in mind, or perhaps you don't understand what it means to practice independently. I can assure you with 100% certainty, that your rigorous training would not provide you with the skills to practice independently in the same scope as MD trained physicians. I'm sorry to break the news to you.
   
3. I'm sorry to burst your bubble once again, but in the real world primary care setting, you are not on even playing fields. The reason you feel this way is because you simply don't understand what being a primary care physician means. And you believe, foolishly, that your NP training provides with the skills to practice independently on par with the MD trained. I'm here to tell you, categorically, you may be able to practice primary care, as defined by you, but you cannot practice in the the same depth of scope as an MD trained internist. As an internist, I am trained to take care of many organ specific conditions independently. I do not call myself a cardiologist or a pulmonologist or a nephrologist because I am not trained to practice a full scope of those specialties independently. As such, you can provide primary care as defined by you, but your ability to provide an equal scope of services is limited as well. Your view of primary care is simply myopic. You will only understand what you experience. And your experience as an NP will be vastly inferior than an MD trained internist. That's not insulting. It's reality. You just aren't trained to do what I do.
   
4. Sometimes the best education is on the job. I am going to have to disagree with on that as well. I certainly would not want you practicing on me as a full scope independent practicing NP when I come to you expecting you to be an expert in your field. As a resident, I had multiple levels of supervision. There were always experts looking over my shoulder, correcting my mistakes and guiding me towards the right answers. I would never subject myself to caring for someone while learning "on the job." If you want to learn on the job, you should go to medical school and get a residency and have a team of experts watch your back.
   
5. Substituting a NP for an internist because there are too few internists is like substituting an eagle scout for a para military special forces agent because all the agents have quit or retired. NP and MD training are not interchangeable. An eagle scout can do a lot, but most can't kill with their bare hands. In the same regards, NPs may be able to do a lot of what MDs do (including specialists), but they also can't do a lot of what most MDs do. I don't understand where in the course of training, folks decided that NPs could practice independently in primary care but not subspecialty care. There is nothing special about being a subspecialist, except the extra several years of training. I would suggest that NPs take a 500 hour clinical experience, do ten heart caths, ten TEEs and become certified as independently praciticing cardiology NPs. The suggestion that these NP cardiologists were "on even playing field" with their MD cardiologists would be laughed out of town by just about every health care entity in this country. I view with hilarity the same assertion that NPs and internists are on even playing fields. The several years that differentiates my practice of cardiology from a cardiologists practice of cardiology is the how I think about NP vs internist training. In fact the difference is much greater do to the lack of medical school level education. I would never claim to be a fully independent practicing cardiologist because I am not qualified to do so. As such, the insinuation that an NP can practice outpatient internal medicine independently is absurd. And any NP who believes they are "on even playing fields" is ignorant of their own ignorance. You are the type of practicing provider I fear the most. Just as I would fear myself if I claimed to be an independently practicing cardiologist. This is reality. Your scope is simply not anywhere near the depth of scope a physician is capable of. You can define your scope as you wish. But understand, your lack of training does not provide you with the same capabilities as an internist. But your claims of being "on equal playing fields" is intellectually dishonest. You have medical skills. You also have nursing skills. You don't have internal medicine skills. Sorry to be the one to tell you. And internal medicine skills are required to practice a full range of outpatient primary care.
6. I have no illusions about the "status" of MDs as you call them. I find myself no more special than the cable guy. I am trained to do what I do because I invested the time and energy, determination, hard work, sacrifice and delayed gratification to excel in the practice of internal medicine.. I would expect nothing less from my physician caring for me in my time of need. You believe I think physicians are better. I don't. I think they are much better trained. As they are. By exponential amounts on the basis of their education and experience as medical students, residents and practicing doctors. That doesn't make me better than you. It makes me more educated than you. And that makes my scope vastly superior to practice internal medicine than those who haven't experience the rigorous training. I respect everyone for their contributions to this world we live in. But to believe you are on an "even playing field" is a clear indication of your lack of insight into what primary care is and what you believe it should be. I ask you go read Dr Centor's blog as indicated below.
   

Dr Centor over at DB's Medical Rants does a great job summarizing what I believe to be the semantics of this discussion. Primary care is misunderstood. It's misunderstood because those not trained to provide it don't understand what the scope entails. Many folks believe it means primary prevention. Dr Centor discusses below the difference between primary, secondary and tertiary prevention.

Yet, we know that high quality primary care does save money. I believe Verghese is making the classic mistake of defining prevention only as primary prevention. Those who study epidemiology and health services research understand that the real value occurs in secondary and tertiary prevention.

Time for some prevention definitions:

1. Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.
2. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptom.
3. Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications

As most medical students, residents and fellows can attest too, the vast majority of our training is spent managing complications of disease, not the disease itself. It is impossible to appreciate how to manage a disease, without seeing the thousands of permutations of complications that present themselves. It is difficult, to nearly impossible, to be an excellent provider of medical care if you don't know how to manage the complications. It is difficult to understand how to proceed with secondary and tertiary management of disease without first becoming an expert on the complications of those disease.

This is where the magic of residency and fellowship happens. As physicians, we are experts in complication management. Primary care is not primary prevention. Primary care is primary + secondary+tertiary prevention. And it is complication managment when those efforts fail. It is with MD level training that one begins to appreciate the subtle nuances required to understand the physiology and pathophysiology in patients with chronic medical disease. How multiple medications interact. Their side effect profiles. Their complications and exacerbations. This is not primary prevention. This is primary care. This is internal medicine. It is a rigorous process where we learn to differentiate patients from guidelines and make medical judgments on an individualized basis. You can't learn a full scope of this in NP school. You can't learn this after 50 years of nursing. You learn it by studying the full skill set necessary to achieve that end.

So Jane and Stephan, I respect you. I respect you for your skills. I respect you for your education and desire to advance your patient management skills. You have me all wrong if you believe I believe you have no value in patient care. You do. And you have an important role in patient care. But you can't do what I do, no matter how many years of on the job training you experience. I will not back down on my assertion that independently practicing NPs should be held to the same standards as all other independently practicing MDs. You may practice primary care, but you don't practice family medicine. And you don't practice internal medicine. You practice primary care, some vague unknown entity that you have defined by your own skill set.

Perhaps the fact that most of the public has no idea how to differentiate internists from family medicine MDs from NPs works in your favor. Perhaps you have gained legislative equality in many districts at the expense of educational equality. That's something that will eventually play itself out. I do know, based on my own training and experiences that should I ever find myself in a condition that requires the skills of an internist, an internist is where I am going. An internist who has far more to offer than primary care.