Twenty-eight states are now engaged in a heated debate over the difference between a doctor and a nurse: Legislators in these states are considering whether they should let a nurse practitioner (NP) with an advanced degree provide primary care, without having an M.D. looking over her shoulder.  To say that the proposal has upset some physicians would be an understatement. Consider this comment on “Fierce HealthCare”:

“An NP has mostly on the job training…they NEVER went to a formal hard-to-get into school like medical school,” wrote one doctor.

“I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpinning principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive. HEY NURSIE, IF YOU WANT TO WORK LIKE A DOCTOR…THEN GET YOUR BUTT INTO MEDICAL SCHOOL AND THEN DO RESIDENCY FOR ANOTHER 3-4 YEARS. NO ONE IS PREVENTING YOU IF YOU COULD HACK IT!” [his emphasis]

Fortunately, not all physicians exhibit the same degree of rancor. Some support the movement. Another reader notes the commenter’s emphasis on just how brutal med school  can be: “The anger reflected in the previous comments reveals not only the writers’ ignorance of scholastic achievement required of Nurse Practitioners, but mainly their fear that NPs will not be under physicians’ control…Many older doctors’ schooling and experience was conducted in punitive ways, sacrificing self esteem. It seems that anything less, isn’t sufficient.”

The American Medical Association (AMA) represents many members of the old guard, and is intent on protecting the guild.  In some statehouses, the Associated Press (AP) reports: “Doctors have shown up in white coats to testify against nurse practitioner bills. The AMA, which supported the national health care overhaul, says that a doctor should supervise an NP at all times and in all settings. Just because there is a doctor shortage, the AMA argues, is no reason to put nurses in charge and endanger patients.”

But others argue that Nurse Practitioners have the needed training and that, in fact, doctors who have gone through the full medical school curriculum are over-qualified for a job that, today, is more about coordinating care than medical science.

Who Are Nurse Practitioners?

This raises the question: just who are these nurse practitioners, and how skilled are they?  Nurse Practitioners are registered nurses with a graduate degree, usually a masters, though by 2015, a doctorate, or a DNP, in nursing practice will be the standard for all graduating nurse practitioners, says Polly Bednash, executive director of the American Association of Colleges of Nursing. The profession sprang up in the 1960s, partially in response to a shortage of primary care physicians in rural areas. This was the decade when doctors began to specialize. (With the passage of Medicare legislation in 1965, suddenly there was more money on the table to pay specialists, and at the same time, medical knowledge was advancing at a breathtaking rate. More and more physicians wanted to become part of the well-paid vanguard, on the cutting edge of medical science.)

Today, the share of medical students who choose primary care continues to drop. Health care reformers hope that the legislation will reverse the trend by providing better compensation for primary care physicians, and by offering generous scholarships and loan forgiveness to med students who choose primary care.

This should definitely help. But if we are going address the needs of a population where chronic illness is now a much greater problem than acute diseases, we desperately need more primary care providers. Today, Managed HealthCare Executive reports, “nurse practitioners are the only healthcare professionals” who are pursuing primary care in “increasing numbers.”

Although there are many NP specialties (such as acute care, gerontology, family health, neonatology, pediatrics and mental health), about 80% of NPs have chosen primary care.

We need health care providers who want to be on the front line of managing chronic disease. NPs don’t seem deterred by the relatively low pay. Wealth is relative: while NPs, like most professionals, would like raises, they are not comparing their incomes to the $450,000 that an orthopedic surgeon might bring home.

This may help explain why research shows that patient satisfaction is often higher among patients who see NPs. These days, many primary care docs are burned out— and if a doctor isn’t happy in his chosen profession, chances are his patients will sense his malaise.

Low morale among PCPs is understandable. As a post on the Yale Journal for Humanities in Medicine (YJHM) blog points out:   “Compared to other physicians, primary care doctors are at the bottom of the social order in the medical hierarchy. They are also among the lowest paid despite the many time-consuming tasks such as filling out insurance forms, drug refills, nursing home and hospital documents that must be read and acted on. These are in addition to the many coordinating responsibilities that they perform for their patients.

“For most of these tasks, many primary care doctors are actually ‘over-qualified.’” YJHM continues. “Clearly, while they have taken on the role of health care ‘coordinators’ they have become more dependent on specialists to take care of the sickest patients. Their ‘scientific’ medical role has decreased while their ‘coordinating” role has increased. For many primary care physicians their medical training is of less importance in their new roles.

“It is wrong to insinuate that nurse practitioners do not have the medical training necessary to perform some and even many of the tasks that primary care doctors now perform,” the YJHM blog concludes.

Let me be clear: not all primary care doctors spend most of their time coordinating care and referring patients to specialists. In parts of the country where there are fewer specialists, PCPs do more of the work of diagnosis and treatment themselves. In addition, many primary care physicians work in large mutli-specialty practices where they are far less likely to be immersed in paperwork; often they are actively involved in teaching patients to manage their own chronic diseases. But it is true that the internist working solo or in a small private practice in many cities often finds himself/herself mediating care rather than providing care.

As for nurse practitioners, as they become a growing force in the medical profession, morale among them is rising. Twenty-three states now credential nurse practitioners as primary care providers, and given the legislation under consideration in states nationwide, that number is bound to grow. Nurse practitioners are feeling empowered. In 1990 there were 30,000 NPs in the U.S.  Today there are 115,000 according to the American Academy of Nurse Practitioners (AANP). And they know that they can do everything a doctor does: take the patient’s clinical history, perform physical exams, diagnose disease, order and interpret laboratory radiographic and other diagnostic tests, and prescribe medications.

NPs can prescribe under their own signature in every state, although in four, including Florida and Alabama, they cannot prescribe controlled substances and narcotics. This can make pain management difficult.

While NPs Earn Less, They Spend More Time with Patients

Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85% of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60. If these nurses provide primary care, this “saves money for the Medicare program,” Jan Towers, PhD, director of health policy for the American Association of Nurse Practitioners (AANP) points out.

In 2008, median pay for primary care doctors was $186,000 according to the American Medical Association, though some primary care docs make much less. Median income for nurse practitioners now averages $83,000 to $86,000.

Nurse practitioners also help rein in health care spending because they “advocate prevention and health promotion,” says Towers.  “As a result, there are multiple studies that show lower rates of emergency room visits and a lower number of hospital days by patients.”

Going forward, I suspect that nurse practitioners will help run many of the new community clinics that reform legislation is funding. There, they will create the medical homes that newly insured low-income patients need, and help keep them out of ERs.

How will they do this?  Research published in BMJ suggests that NPs spend more time with patients than doctors do, and simultaneously, cut costs.  A study by Avorn and colleagues published in the Archives of Internal Medicine supports the thesis. The study used a sample of 501 physicians and 298 NPs who responded to a hypothetical scenario regarding a patient with epigastic pain (acute gastritis). The doctors and nurses were able to request additional information before recommending treatment. If they took an adequate history, the provider learned that the patient had ingested aspirin, coffee, and alcohol, and was under a great deal of psychosocial stress. Compared to NPs, the physician group was more likely to prescribe a medication without seeking the relevant history. NPs, in contrast, asked more questions, obtained a complete history, and were less likely to recommend prescription medications.

A 2004 study by Mundinger, Kane, and colleagues is now considered the most definitive research on the quality of NP care. It explored the outcomes of care in patients randomly assigned either to a physician or to a nurse practitioner for primary care after an emergency or urgent care visit. The NP practice had the same degree of independence as the physician: this made the study unique. After analyzing the services that patients used, and interviewing some 1,136 patients, the researchers determined that the health status of the NP patients and the physician patients were comparable at initial visits, 6 months, and 12 months. A follow-up study conducted two years later showed that patients confirmed continued comparable outcomes for the two groups of patients.

Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health rejects the argument that patients’ health is put in jeopardy by nurse practitioners. “There’s no evidence to support that,”  Needleman told the AP. “Other studies have shown that nurse practitioners are better at listening to patients. And they make good decisions about when to refer patients to doctors for more specialized care.”

Nurse Practitioner midwives also receive high marks. They attend 10% of all births in the U.S., 96 percent of which are in hospitals. A number of studies of low-to-moderate-risk women giving birth show that after controlling for all social and health risk factors, the risk of infant death with a nurse-midwife is as much as 19 percent lower, neonatal mortality as much as 3 percent lower, and low-birth-weight infants up to percent fewer than with physician-delivered babies.

Other studies reveal lower rates of caesarian sections, as well as significantly fewer infant abrasions, perineal lacerations, and complications.

Researchers point out that it is possible that mothers who choose nurse practitioners to deliver their babies are healthier, or less inclined to want caesarians. But at least one study of high-risk mothers in an inner-city hospital suggested that midwives provide equally safe care in these more difficult cases.

Some NPs point out that they must do better. As Chicago nurse practitioner Amanda Cockrell explained to the AP: “We’re constantly having to prove ourselves.”

Medical evidence that NPs offer as good or better care threatens some physicians. “They’re really scared that we’re going to do something that will take money away from them. As long as we went out and only gave healthcare to poor people, nobody said anything,” Dee Swanson, president of the American Academy of Nurse Practitioners, told earlier this month. “Let’s face it: We have a crisis in primary care in this country, and it’s an area that physicians have not been interested in, or there wouldn’t be a shortage.”

Some Insurers Balk at Paying NPs; Reformers Reward Them

Despite all of the convincing data about the quality of care that NPs provide, “Acceptance by health plans varies across the country,” the AANP’s Towers told Managed Care Executive. “Some are fully onboard in certain parts of the country. But in other sections, health plans are still hesitant and require strings that we believe are unnecessary.

“Then there are cases where you work very well with a company, but there is a merger with a company that hasn’t worked with nurse practitioners,” Towers adds. “You have to start all over again.”

In California, where insurance plans do not recognize nurse practitioners, the state’s more than 10,000 NPs are beyond frustrated. Although private insurers pay for the services offered by NPs, they do so as if the NP’s collaborating physician provided the care. (This may give the insurer an opportunity to pay less for the same care.)

In states where insurers shun NPs, patients are unable to name a nurse practitioner as their primary care provider, and this can lead to confusion. In addition, patients looking for a new primary care provider will only find physicians listed in their insurance company web sites and printed materials, even if well-trained nurse practitioners are available to serve them. (I can’t help but wonder, have these insurers succumbed to pressure from physician lobbies?)

When reform legislation kicks in and millions of formerly uninsured Americans begin to look for a PCP, many patients won’t be able to find a provider in California—unless the law changes.

This is one reason why the Josiah Macy Jr. Foundation, which funds programs designed to improve the education of health care professionals, recently recommended that regulators immediately act to remove legal and reimbursement barriers preventing nurse practitioners from providing primary care, and to empower them to lead multidisciplinary teams of primary-care providers. Dozens of health care organizations signed the report; the AMA was not among them, but the American College of Physicians was.

The Foundation’s proposal that nurse practitioners should manage health care organizations upsets some physicians. If NPs ran community clinics, they might supervise doctors, and even oversee programs training residents in primary care. “I would never want to see the nurse leading the team in a patient-centered medical home,” Dr. James King, President of the American Academy of Family Physicians, said in 2008.

But the times are changing. Unlike some insurers, legislators who crafted health reform legislation seem to have paid attention to the research on quality. They are offering the same financial incentives to nurse practitioners that they offer to physicians:

  • 10% bonuses from Medicare from 2011-16 to primary care providers, including nurse practitioners
  • $50 million to nurse-managed health clinics that offer primary care to low-income patients.
  • $50 million annually from 2012-15 for hospitals to train nurses with advanced degrees to care for Medicare patients.
  • Moreover—and here’s the surprise—the legislation boosts the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor’s.

A Nurse’s Training– It’s Not the Same

These days, nurse practitioners are spending more time in school. For example, on top of four years in nursing school, Chicago NP Amanda Cockrell spent another three years in a nurse practitioner program, much of it working with patients.

By 2015, the American Association of Colleges of Nursing will require its approximately 200 members to offer a Ph.D. Johns Hopkins already has rolled out a forward-looking graduate program for nurse practitioners that focuses on evidence-based medicine.

But even while nurse practitioners put more years into education, both supporters and critics agree: the training is not the same.

Daniel Lucky of Modesto, Calif., an NP adjunct nursing lecturer with University of Southern Indiana and adjunct faculty for Indiana State University, says that nurse practitioners take a different approach:  “NP practice is based on the nursing model of care–not the medical model,” he wrote in a commentary for the Evansville Courier Press. “Nursing teaches us that we should not reduce human beings to mere signs and symptoms, place a disease label on someone, give them a pill and send them off. As nurses we are trained to look at the entire patient from a holistic perspective and then, actively partner with the patient and family to not only correct problems, but also enhance optimal health. Nursing care places the patient–not the provider–as the central focal point.”

Critics put it differently: Texas physician Gary Floyd opposes giving nurse practitioners too much autonomy by arguing that “Nursing schools push a ‘care and comfort’ approach to giving care.”  Floyd, who serves on the Texas Medical Association’s Council on Legislation, contrasts training in “comfort and care” to “the scientific perspective of medical schools that teach about disease processes and bodily interactions.”

Here, I have to differ. As a patient, I’m a big fan of “comfort and care.”  Not all diseases can be cured. If I were suffering from a curable disease, I would trust the vast majority of nurse practitioners to refer me to a specialist who might know how to conquer the disease. Otherwise, I would like to stick with the provider who focuses on talking to me, listening to me, comforting me, and making sure that I’m not in pain.

Health care reform means that we need to re-think medical school education. We don’t want to continue to train young doctors to fit into a system that we know is dysfunctional. Many medical educators suggest that we are making students take science courses that will be of little help when they actually practice medicine. Depending on his or her specialty, not all physicians need the same in-depth understanding of body chemistry or anatomy. Students are forced to memorize information that may well change as medical science evolves over the next five or ten years. When they are treating patients, they will look up the newest information on best practice, or the ideal dosage for patients who fit a particular medical profile,

In a 21st century medical school, many argue, students need more training in patient-centered medicine: how to educate patients so that they can collaborate in managing chronic diseases; how to share decision making with patients; how to manage pain;  how to tailor end-of-life care with an eye  to the individual patient’s greatest desires and worst fears.

Don Berwick, President Obama’s candidate to head the Centers for Medicare and Medicaid, defines patient-centered care in a way that sounds much closer to the nursing school model. Berwick argues that it’s all about asking the patient: “What do you want and need?” “What is your way?” “How am I doing at meeting your needs?” “How could I do that better?” “How can I help you?”

Isn’t that what nurses—and even doctors—once asked?

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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62 Comments on "Nurseanomics"


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Cassie Stegeman
Dec 30, 2012

Where does the physician assistant fall into this discussion? Do some doctors believe that PA will replace them also? Just a thought.

Apr 26, 2012

“But others argue that Nurse Practitioners have the needed training and that, in fact, doctors who have gone through the full medical school curriculum are over-qualified for a job that, today, is more about coordinating care than medical science.”

I believe this quote demonstrates one problem facing the U.S. healthcare system. We focus entirely too much on specialists. If we empowered our primary care physicians, they could spend a lot more time caring for patients and practicing medicine rather than keeping track of the specialists a patient sees.

Jun 16, 2012

Platon20: Very misleading statistics. The main track at the UTexas NP program only graduates mental health NP’s to staff the prisons and rural mental health institutions that Texas likes to hide in nowhere land.

NP programs do have specialties. Specialty practice tends to require direct supervision from a MD.

MD’s at these institutions are paid 300K plus of pure public money. NP’s are still earning sub-90s.

Apr 23, 2012

This article is wrong for the following reasons:

1) NPs and PAs hate primary care even more than MDs do. When an MD subspecializes to make extra money, its a 3 year minimum time commitment for extra training. For PAs and NPs, going to a subspecialty requires ZERO extra training. Thats right. An NP working in family practice can choose to go to ear/nose/throat surgery and TRIPLE her income with zero extra training. Is there any surprise that NPs and PAs are choosing subspecialties in droves? In fact, the pressure for midlevels to subspecialize is even HIGHER for midlevels than it is for doctors. Here’s a little anecdote to consider: The university of texas graduated 127 midlevels last year, and NOT A SINGLE ONE OF THEM WENT INTO PRIMARY CARE! How’s that for midlevels “solving” the primary care shortage? The midlevels are just as “greedy” as the doctors are!

Feb 23, 2012

This debate brings to mind the legal doctrine of a “slippery slope.” I do think that for patients that simply need medications checked and verified, forms filled out, and referrals made an NP would be more than capable. But where do we draw a line? In 10 years will we be debating if they should be allowed to do scopes? All patients deserve to receive the best care and I’m not convinced that the training, knowledge, and capabilities of an NP are even remotely equivalent to those of a physician. This just feels like settling for good-enough, a premise of the public health field, and seeking convenience instead of solid answers for how to have patients seen and cared for by medical experts.

Oct 14, 2011

Nice, thoughtful, substantiated post – thank you. As an NP, I can tell you that my colleagues and I have no interest in competing with or trying to replace physicians. We want to collaborate. Bottom line, we want to take care of people who need to be cared for. Isn’t that the point?

Dec 4, 2010

You never know what you can do till you try.
Frederick Marryat British novelist

Oct 3, 2010

Rather than continuing a turf war we should work collaboratively for the best interest of the patient. With shortages in both physician and nurses it is difficult to believe that there isn’t enough work to keep us all busy.
The safety and effectiveness of nurse practitioners has repeatedly been shown through research. As a CRNA, I worked independently in small rural hospitals without physician supervision. Safely, effectively providing service that would otherwise not be available. No MDA’s were knocking at the door wanting to practice in a small rural town in the USA (making 1/6th what they could in a metropolitan area).
I determined on an individual basis if the client, or the proposed procedure was more than my resources could support and I referred the client to a MDA supported practice if I felt it necessary. In 32 years as a nurse, I have never had legal action taken or even threatened.
The key is recognizing the strengths of every health care provider and utilizing each to benefit the client. Nurses and doctors are on the same team and it is time to realize this. The word for today, and tomorrow, is collaboration.

Cassie Stegeman
Dec 30, 2012

I agree with your comment. Instead of doctors feeling like NP are replacing them they should look at NP helping them with there workload of patient care. Some healthcare professions have a difficult time with change and in today’s world of healthcare change is inevitable!

Stop the madness
May 4, 2010

I read the long blog and the many responses and honestly probably can’t add anything substantive to this discussion but am going to share a few thoughts.
The medical model and the nursing model are not the same at all in the approach to the patient.
Nurse Practitioners, CRNAS and PAs fall under the vague heading of “Mid-level” practitioners. This implies there are practitioners both above and below this level.
Its not like there is an over-abundance of primary care physicians out there now and in the future. This reminds me of when I worked in an ICU and some of the nurses would not let the nursing assistants bathe the patients. When this was questioned the response was “because I do it better Physicians can certainly draw blood and bill patients but long ago decided that was not an efficient use of time that could be better spent treating patients and delegated this work to a different level of health care worker.
I would suggest rather than “circling the wagons” or getting defensive on either side of this discussion, we spend our time and energy on defining what care is best delivered at what by what type of provider and putting that tiered system into place.

Apr 28, 2010

The solution to food deserts? Catering. The solution to Obamacare? Private money. The concierge practice will really take off in the next 5 years. The smart money will want to have their own version of “Hank Med”.

Apr 26, 2010

I do read before I speak, usually :-)
Regarding IT, a solo practice can get enough IT to qualify as a Medical Home with tools that Wendell mentioned. Yes, the IT requirements are stringet, maybe too stringent
In this Internet age collaboration is trivial. Physical collocation is not as important as it used to be and several solo practices should be allowed to virtually collaborate in providing a Medical Home. I believe some of the ACO proposals do allow loose virtual collaboration, although I don’t believe those variations will be adopted. More than likely large multi specialty and hospital groups will be preferred, for the same reasoning you provide, like economies of scale and ability to create management structures.
So basically, we are going to create supermarkets for medical care, just like we did for food stuff. No question, it will be more “convenient” and some things may even be cheaper, not all
As to access, as you probably know, supermarkets have created “food deserts” in certain areas. Same will probably happen with medicine.
And quality, when you want really nice veggies, you go to a farmer’s market.
We need some pause…..
I saw this coming for quite sometime and it scared me then and it is terrifying me now. I’m just going to go write a long rant about this…. I’ll post the link when I’m done, instead of cluttering this thread.

Apr 26, 2010

I believe they are called pathology assistants and not NP’s. As a pathology assistant I wouldn’t dare try to diagnose tissue under the scope, rare or not. The pathologist could not be replaced by PA’s. They have much more knowledge and the risk they take would make me ill. I watch them diagnosis tumors at frozen section (patient is operating room table) where what they say influences what the surgeon will do to the patient in real time and I am in awe. Is it tumor or is it just inflammation? Is the sentinel node positive or is it negative? Are you sure? You better be since the patient may go on to get a full axillary dissection.
I don’t need to read the studies—i live it.

Apr 26, 2010

Well, I am not a physician either, so here it goes.
The notion that NPs should provide Primary Care or Specialist Care, instead of a physician, translates into the argument that we need less trained, less qualified and more compassionate (maybe) resources to provide medical care. How does this correlate with the intent of providing better care? Or is it just cheaper care we are after?
Are we suggesting that compassion is a good replacement for competency? I can see how it’s cheaper.
Wendell, the separation between run of the mill conditions and the rare occurrences is fine if the NP is part of the physician led team, where a physician can delegate certain tasks, but is always there, on premise, for others.
NPs and PAs are extremely important resources that can help improve access and reduce cost of care, but IMHO we are not at a point where we are financially forced to revert to third country world status and provide health care without doctors. Or are we, and we are just trying to convince ourselves that this particular misfortune is actually a good thing?

Apr 26, 2010

Bev M.D.Wendell, racemic
Bev M.D.
In your first comment, you note that you “only skimmed Maggie’s long and fine print post.”
Fine print???
Nevertheless, you seem to feel fully qualified to declare that I am wrong, and to launch a rather snarky person attack.
I’m afraid that the majority of docs who actually read the post seem to disagree with you. If you read the comments on HealthBeat ( following this post, you will note a number of them saying that some NPs can do many things as well as they do–in some cases, better. (One doc mentions that the NP who works in his practice independently most of the time can do 95% of all things as well as he does. And in a second comment, he says there are things she does better. In those 5% of cases, where she needs to, she consults with him–much as you might consult with another doctor about a puzzling case.
(If, that is, you are ever puzzled.)
If you read the studies I cite in the post, you’ll find more evidence of high quality. But how can I expect that you looked at the studies? You didn’t even read the post.
If you did, you would know that nurse-midwives are better at delivering babies of average-risk women: they are far less likely to induce labor, and they perform far fewer C-sections.
Maternal mortalities are rising because doctors in many states are performing way too many C-sections. (Another case of unwarranted geographic variation In some places 40% of births are C-sections, and the biggest increase is among women under 25 having one baby.)
Bev, I get most of my information from M.Ds — and from peer-reviewed medical journals. Over the years (since I began writing my book in 2003) I’ve come to know many doctors. Just today, a primary care doc who I have never met called me from Ohio. We talked for an hour.
Finally, I tend to believe medical evidence– studies and research in peer-reviewed journals.
You opinions tend to be more anecdotal, based on your own personal experience as a doc. That’s fine. But one person’s experience or beliefs just can’t counter reams of evidence.
For example, on another occasion, I recall you disagreeing with what the AHRQ said about “watchful waiting” as an appropriate strategy for men with high Gleason scores diagnosed with with early-stage prostate cancer. You said you disagreed based on your clinical experience. I asked if you’re a urologist. You nevver answered. If memory serves, you also have strong opinions about Gaadasil- the “vaccine” for cervical cancer—opinions contradicted by recent research. Are you both a gynecologist and an urologist? Must be an interesting practice.
(And if memory serves, when we were discussing treatments for prostate cancer, you suggested I couldn’t possibly know what I’m talking about because I’m not an M.D. But I can read, and I do find that the AHRQ does excellent research–which has been confirmed by others. The opinion of one doc really wouldn’t persuade me that the AHRQ, etc., all are wrong.
As for NPs, there have been many studies of NPs– some NPs are very good; some aren’t. Docs tell me that some NPs are better at diagnosing than some docs. I’ve found that the doctors who are most skeptical about NPs haven’t worked with them very much. . . ..
As you might say: Ah me!
Thanks. Yes, Berwick defines patient-centered care as far less physician-centric. And I agree. Traditionally, doctors have seen themselves as “in charge.” They tell the patient what he should want. People who aren’t M.D.s just can’t possibly understand.-
On IT, I was talking about the IT required for a medical home. What you are describing wouldn’t be sufficient.
The primary care provider(s) is(are) expected to have ” Health information management systems that include electronic health records (EHRs) and clinical decision support tools to improve quality and efficiency. They could offer Web portals that allow patients to access lab results or monitor a chronic disease.” They also would have IT that allows them to share records, information etc. with specialists. (IN a medical home, the primary care doc is supposed to co-ordinate specialist care.)
The Medicare Demonstration for Medical Homes contains what it calls “stringent IT requirements.”
For many solo or small practices this could be unaffordable. Moreover, it would represent a terrible waste of health care dollars for zillions of small practices in large cities and suburbs to all invest in their own IT (not to mention the nightmare of co-ordinating it.) In rural areas, this may be be necessary. But if we’re going to streamline health care we want less redundancy. This is why ultimately, medical homes are more likely to be found in large multi-specialty practices where everyone is already using the same IT. We’ll also find medical homes in the many new community clinics that are being built under the new legislation.
Racemic– See my reply to Bev M.D. I rely on medical evidence and research. She (and you) seem to rely primarily on personal opinion, prejudices and beliefs. This means that you are likely to be wrong fairly often.
I’m sorry about that, but I’m not going to apologize for doing the research and checking my facts. If that makes me right more often, do be it.
I rather doubt you read any of the studies mentioned in my post. If you are particularly interested in pathology, I suggest that you Google “Nurse practitioner pathologist” and studies. You might find the research eye-opening.
Actually, I do mention nurse practitioner pathologists. Typically, they analyze a large sample of tissue, then an M.D. takes a closer look at a smaller sample. Studies show that they do very good work.
But I didn’t talk about nurse practioners diagnosing rare diseases. I wouldn’t expect they would be very good at that. I would add that most primary care docs are not very good at diagnosing rare diseases– unless they have specialized in some way, or spent time working in tropical or other regions where you see more rare diseases.
Just going to med school and through a primary care residency doesn’t make you a brilliant diagnostician.
And, unfortunately, some of our primary care residencies are pretty poor– as are some nurse practitioner training programs.