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Nurseanomics

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 ModernHealthcare.com 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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  1. 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!

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

  3. 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.

  4. “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.

  5. 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!

  6. 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.

  7. 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?

  8. 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.

  9. 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.

  10. 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”.

  11. Maggie,
    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
    http://www.annfammed.org/cgi/content/full/8/2/108
    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
    http://www.nytimes.com/2010/03/26/health/policy/26docs.html?src=me&ref=health
    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.

  12. Maggie,
    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.

  13. 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?

  14. 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 (www.healthbeatblog.org) 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!
    Wendell–
    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.
    Wendell–
    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.

  15. Wendell,
    I did read Maggie’s article and posts. She does mention nurse pathologist’s. Check it out.

  16. racemic:
    It might be helpful if you read what other people write.
    “The idea of having any individual without a four to five year residency after medical school and then a fellowship diagnose rare diseases or even stage a routine colon carcinoma is outrageous.”
    I do not see anyone disagreeing with this statement. That is not the point of Ms. Mahar’s posting here. Her point is that ancillary (i.e. non-physician) medical service personnel can satisfy adequately a high percentage of patient needs. That is all. Those with knowledge and experience with less frequent conditions should be available to deal with those. No one disagrees with that either.
    I do not know whether you are a physician but this is a classic of physician arrogance that turns everyone off:
    “Until you can do that stick with what you do for a living”
    including I suspect many physicians themselves.
    Also as I usually note in these cases you might drop the facade and post your real name. It might make your comments more credible, not to mention more responsible.

  17. Thanks bev MD. I got the feeling that Maggie believes she always right. That is a shame to go through life thinking you are always right. Leaves little room for anyone else.
    Wendell as a bottom feeder in medicine, I realize all to often that I am a servant to other physicians and a patient advocate. The idea of having any individual without a four to five year residency after medical school and then a fellowship diagnose rare diseases or even stage a routine colon carcinoma is outrageous. I wouldn’t want my lung removed by a nurse pathologist.
    Wendell you have no idea what you are talking about unless you actually put your name on the line. Until you can do that stick with what you do for a living.

  18. “A solo practice probably could not afford the IT required.”
    This simply is not true. A solo practice can easily afford an application such as AmazingCharts or PatientFusion or openEMR, etc. that is easy to set up, has nominal or no licensing cost and performs adequately in any small practice setting.
    In addition this description of a small practice in Colorado Springs describes how it is done: http://innovations.ahrq.gov/content.aspx?id=2196
    It does not take much.
    “This is absolutely ridiculous. Nurse cardiologist, nurse pathologists, nurse surgeons.”
    Not sure which of the comments above racemic refers to with this statement, but the gist of this posting are these sentences toward the end of the posting shown below.
    Patient perspective – not physician perspective – is the perspective that should rule on how medical services are provided. That is of course contrary to the development of medical services in the USA over the past century or so. The ever-present physician-centric perspective is evident in racemic’s brief comment. Wake up physicians: your patients are your customers and you are their servants.
    “… 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?””

  19. Racemic;
    Lesson #1 – never argue with Maggie. She is always right, and you are always wrong – whether you have an M.D. and are arguing a point of actual medical fact or not.
    But, I will try once again – aside from completely agreeing with racemic’s last comment, Maggie is also incorrect that NP’s can provide primary diagnosis as well as M.D.’s. This is because Maggie, having no medical training herself, cannot imagine the rare diagnoses sometimes hidden in a pedestrian symptom presentation, which NP’s have never heard of (having not had the length of training to have heard of) but a good primary would pick up.
    Medicine is inherently a needle in a haystack phenomenon. Ordinary illnesses are the haystack, rare illnesses masquerading as ordinary ones are the needle. Who shall see the needle, and who will live or die as a result?
    Now wait for the inevitable rebuttal.
    Ah, me; back to wait for the inevitable rebuttal.

  20. This is absolutely ridiculous. Nurse cardiologist, nurse pathologists, nurse surgeons. Are out of your mind? Do you have any idea how long it takes to become any of the above as MD’s? Good Lord. Do you have any idea the responsibility involved in these specialties? You really have a problem with doctors and the amount of money they make. Why is that?

  21. twa, Infomark,John E., Bev M.D., Margalit, Devon, Inchoate, Incognito, Carla, Wendell, John E (on lawsuits), Gary, JLF, John E& Misogyny.
    twa–Thank you– an excellent comment. I’d urge everyone to “search” the thread for your name and read it.
    Infomark– Thank you. And I agree, while doctors are taught to “direct” patients NP’s are taught to teach– which is very helpful if you are treating chronic diseases. Teaching the patient to participate in managing his own disease is essential.
    John E– I don’t mention PAs because legislators are not debating whether they should practice independently.
    This post is about that debate.
    Bev M.D.– As you ultimately say, there is no reason to think that the NP would be more likely to miss the breast cancer. The fact that she is paid less doesn’t make her less competent. And if she is trained as a nurse pathologist, who has to assume that training includes an emphasis on gross phathology.
    Margalit– I dont’ think you’ve looked at the requirements for a medical home. The doctor(s) has to be available 24/7. The goal is to keep patients out of the hospital– which means being available to see them or at least talk to them at times when they might otherwise go to an ER. One doctor and one NP probably would not want to be available 24/7.
    Secondly, to qualify as a medical home, you must have IT and EMR. A solo practice probably could not afford the IT required.
    Finally, all of the medical research shows that outcomes are generally better when patients receive cared at large multi-specialty medical centers. These days, one doctor (or NP) cannot know everythign he or she needs to know. Medicine has become a team sport-docs need to be consulting with each other.
    Also– a well-trained NP with 8 years of education, can diagnose just as a primary care physician can diagnose. She doesn’t have to refer to a specialist unless the patient presents with an exotic disease and she has no idea what it is. (In these cases a primary care doc might also have to refer to a specialist or consult with other docs–assuming he’s in multi-specialty medical center.)
    Both the NP and the PCP should be paid for the time it takes to actually make a good diagnosis by taking a complete history, listening to the patient, observing the patient, laying hands on the patient— and then ordering a test or tests to confirm what the NP or doc has seen and heard.
    The economics just don’t work for solo practice in the 21st century. Large mutli-practice centers enjoy huge economies of scale when: buying malpratice insurance; buying HIT; running a back office that does billing, etc; utilities, real estate, medical equipment . . .And by “siloed” care reformers are referring to docs practicing without conferring with each other, no one looking over their shoulder. . . .
    Inchoate– You’re right, we don’t want more siloed care.
    But we do have evidence that outcomes are better when patients receive more primary care. The Dartmouth research shows that in parts of the country more people get most of their care from a PCP, and rarely see specialists, outcomes are as good–or better– then in cities where they see many specialists. (And the care is less expensive) Also, in many European countries, patients receive more primary care, much less specialty care. And outcomes are better.
    Devon– I agree with everything you say. Some of the opposition is simply about money.
    I would add only that government needs to regulate training and certification of NPs (just as it oversees education and certifiation of docs). We don’t want NPs getting their “training” online.
    This, by the way is very unusual– normally an NP program emphasizes clinical hands-on training. But there are NP programs that are not very good–just as there are residency programs where residents are not well supervised. We need to weed out the weak programs in both cases.
    Icognito– I agree that we want to take a close look at NP training programs –though we also need to improve some residency programs (particularly primary care residencies which are often a very low priority at academic medical centers that look down on priamry care.
    It also makes sense that a good NP can do 95% of what you can do. This suggests that she doesn’t need to be supervised while doing the 95%–but that she needs to have out readily available to consult with. In other words, she shoudln’t be alone in an office seeing patients
    But I would argue that as Dr. Don Berwick (soon ot be head of CMS) says, Doctors shouldn’t be alone either.
    Probably 5% of the time, you could use some advice (or a consult) with another doc. If you’re in a group setting you probably do that now. If you’re in a solo practice, you may consult by phone, but often docs wind up playing phone tag with each other–frustrating.
    This is why it makes sense for docs and NPs to work in those larger multi-practice settings. (Except in sparsely populated rural areas where we continue to need small pratices.)
    Carla– Imteresting that the number of NPs going into primary care is dropping. I, too, blame med schools for undervaluing primary care — the attitude seeps out into society. There are, by the way, family NPs, and certification for family NPs.
    That said, I would add that I’m glad to see NPs going into other specialties. NPs don’t enter the profession expecting to make $400,000 a year. They can help bring down the cost of speicalty care as they move into other areas. (I’m not suggesting that they shouldn’t be paid well, but the MDs on the top half or third of the medical income ladder are paid ridiculous salaries that society cannot afford.
    I believe that we should move toward the European model: subsidizing medical school, and paying specialists significantly less than we pay them now. I think this will happen over time, and NPs will help the evolution in this direction.
    Wendell– I agree. What you say reminds me of how NP midwives practice: normally, they deliver babies in hospitals where this are OBGYN’s around– if the mother or baby get into trouble, the NP midwive will call for help, but otherwise, she can deliver babies without supervision. (And research shows that with an NP the mother is significantly less likely to wind up having a C-section. Also NPs are less likely to induce labor-which can, in turn, lead to the C-section. This is all safer for mother and baby.
    John- NPs are sued far less often than MDs. Many reasons for this. We know when patients sue it is often because they viewed the doctor as arrogant and cold from the begining. Also NPs tend to be more patient (waiting out a natural delivery, for instance) and their training emphasizes patient-centered care (as opposed to doctor-centered care.)
    Gary- -The majority of NPs are women. So “she” is the appropriate pronoun. If I were writing about fighter pilots I would say “he”. I find the “he or she” awkward.
    JLF– Yes, I’ve noticed that docs who are most critical of NPs seem to have had little experience with them.
    Finally, let me note that some (certainly not all) of the resistance to NPs is pure misogyny: John sums up that sentiment nicely: “For the Maggie crowd — men always wrong, women always right. The sisterhood is powerful.
    Privatize all public agencies. Let the rich widows — women live longer than men — fund feminism.
    “Rich widows”? Wow, John E., I guess you are bitter.

  22. YUP, YUP, YUP
    For the Maggie crowd — men always wrong, women always right. The sisterhood is powerful.
    Privatize all public agencies. Let the rich widows — women live longer than men — fund feminism. Because as long as playing the sexism-card, the race-card, the victim-card pays the bills — there will always be “victims.”
    ///////////
    Sorry John, you get so angry you forget to read. You said 58% of medical STUDENTS are women.That’s different than medical school APPLICANTS. Maybe a greater proportion of women who apply get in than men – or not.

  23. Sorry John, you get so angry you forget to read. You said 58% of medical STUDENTS are women.That’s different than medical school APPLICANTS. Maybe a greater proportion of women who apply get in than men – or not.
    As for nurses, surprisingly I agree with you that many don’t like to take orders from docs. Especially woman docs. But some nurses I knew were better than some docs I knew, gender notwithstanding.
    The rest of your comment makes no sense so merits no discussion. Feel free to rant on without me!

  24. I strongly believe that it is time that politicians who are trying to pass laws like making midlevels into the equal of the primary care physician should have to have only midlevel doctors for them and their families with no access to any primary care physician.

  25. HOMER(A) SIMPSON HERE?
    1. Title of this fact-jejune pedant: “nurse-conomics.” Yup, it is the m-o-n-e-y.
    2. The MD/RN fight has gone on for nearly 50 years. RNs do not want to take orders from MDs. There is nothing new here. (Yeah, yeah — this is woman-hating, blah, blah, blah. And Obama has executive experience.)
    3. ” .. your comment that women who go to medical school are man-haters.”
    Madam — can you read? This pendant is about man-hating (MDs). And for the SECOND time — ” .. BTW: the majority of MD students are now women (58%) ..”
    As for this — “The real question is, what’s the gender ratio of medical school applicants.”
    Well .. if women are 58% .. the hetero-normative answer about non-women is 42%. Then, again, if you’re Obama and his dupes, the answer is “not good enough — sexism-card, race-card, more welfare, more taxes, gimme more, gimme more, blah, blah, blah ..”

  26. jlf
    “You remind me of my current physician supervisor.”
    Apparently your supervisor is highly intelligent and very good looking.
    “So disgruntled over reimbursement. And the very reason patients aren’t getting what they really need!!”
    Apparently being a nurse does not require the skill of forming complete sentences (or diagnosis)as required for an undergraduate degree.
    “Actually your comments speak volumes of your character.”
    Actually they speak more to my ability to use sarcasm to make a point and your inability to recognize such.
    “I am assuming you are a physician.”
    I am not a physician, but thanks for jumping to this wrong conclusion. Just hope you don’t jump to similar wrong conclusions now that you are almost a “doctor”.
    “The uber-conservatives will need to take their heads out of their arse soon”
    I am not sure where this came from or how this supports whatever point you are attempting to make, if any.
    “But you obviously do not have a working relationship with a nurse practitioner”
    Mostly anecdotal, but have had a small number (3) of experiences where I was caught between a doctor (a specialist no less) and a nurse practioner. Outcome was specialist 3 and 0 on being right and professional (although a bit condescending)and the NP being wrong, inflicting pain unnecessarily attempting a procedure she obviously was not competent doing, unprofessional, and ultimately petty by critizing the doctor behind his back to the patient (0 for 3 in my book).
    I’ll pay 10% more for a real doctor. I’d even pay more for nurses that don’t bitch, but my network does not make that distinction, yet.
    LD

  27. John; I am just interested in your comment that women who go to medical school are man-haters. I went to a southern school and it’s the first time even I have heard that one.
    (and yes, I was asked during the interview why I wanted to go to medical school instead of nursing school. I didn’t say it was to make more money, hahaha!)
    The real question is, what’s the gender ratio of medical school applicants. I don’t care enough to look into it.

  28. Golly, no. What’s your problem? Not enough men, apologizing for the past?
    Well, don’t worry — Obama will shovel in a law, forcing men to do that. To help his 2012 election. Since he’s lost the male vote.
    OK — someone pull-out the sexism-card! And the race-card! Time for victim-gets-grant time!
    //////////////
    “Or go to medical school. BTW: the majority of MD students are now women (58%), men-haters.”
    “That is what this is really about — women NPs who want male MD money.”
    Golly, John, got a problem somewhere?

  29. Wow Louisdous
    You remind me of my current physician supervisor. So disgruntled over reimbursement. And the very reason patients aren’t getting what they really need!! It isn’t necessarily your fault that healthcare costs are through the roof. It is a system that has been failing for a long time. But you obviously do not have a working relationship with a nurse practitioner or you would have not made such distasteful comments about nurses or NPs in general. Actually your comments speak volumes of your character. I am assuming you are a physician. I imagine with that attitude, you probably do have high malpractice insurance. The uber-conservatives will need to take their heads out of their arse soon, it doesn’t fit well in the bedpan.

  30. “Or go to medical school. BTW: the majority of MD students are now women (58%), men-haters.”
    “That is what this is really about — women NPs who want male MD money.”
    Golly, John, got a problem somewhere?

  31. What % are women? 80%?
    That is what this is really about — women NPs who want male MD money.
    //////////
    A bit sexist to say ‘her’ in describing NPs

  32. No reason? Really?
    Here’s a reason —
    M E D I C A L M A L P R A C T I C E
    And a 69-word paragraph wasn’t needed.
    Miss something serious — Obama’s lawyer-buddies James Socolove, Sam Bernstein and Lee Steinburg call. Not pleasant.
    Second time — if RNs want to handle urgent cases — become a physician’s assistant (PA).
    Or go to medical school. BTW: the majority of MD students are now women (58%), men-haters.
    My God, Matthew — 3,121 words in this pedant, and not one mention of PAs.
    Seriously brings into question, the knowledge-level and analytic value of the material.
    And what is this debate really about? Could it be m-o-n-e-y?
    ///////////////////////
    The so-called “factory model” which appears to be utter anathema to many physicians is the model applied in industry where all but the otherwise unroutinizable activities are gradually routinized through a rules-based and usually automated system so that lesser trained and therefore lower cost personnel are capable of performing all routine activity adequately, much more productively and at much lower cost as compared to those with much greater expertise.
    No reason that model cannot be applied increasingly in many areas of medical services. The existence of NPs/PAs is obviously a case in point on that, however well or poorly their role is performed from different perspectives.

  33. twa and incognito, not to mention the usual good commentary from bev M.D., seem to me to offer realistic and accurate comments on the situation.
    I have too little experience with NPs/PAs to compare them with family physicians and similar. I have had greater professional (non-clinical) interaction with nurse anesthetists and anesthesiologists than with other types of NPs/PAs. So far as I understand the training for CNAs is extensive. Some of course contend that they do all the work while anesthesiologists “supervise”.
    The situation likely is that cited by Incognito (why not be cognito?) that some percentage of cases, whatever that percentage is, need the attention of an anesthesiologist due to knowledge, training, skill, etc.
    Of course the fact that relatively few cases require attention from the most knowledgeable and experienced of those with knowledge on topic applies to any field.
    The so-called “factory model” which appears to be utter anathema to many physicians is the model applied in industry where all but the otherwise unroutinizable activities are gradually routinized through a rules-based and usually automated system so that lesser trained and therefore lower cost personnel are capable of performing all routine activity adequately, much more productively and at much lower cost as compared to those with much greater expertise.
    No reason that model cannot be applied increasingly in many areas of medical services. The existence of NPs/PAs is obviously a case in point on that, however well or poorly their role is performed from different perspectives.

  34. AMBULANCE-CHASERS: the first time NPs get sued by Sam Bernstein, they’ll want to be RNs again.
    Medical home? Just more targets for Sam.
    Oh. That’s right. Obama’s a lawyer. He doesn’t 99% of a rip about stopping Sam Bernsteins.
    Pathetic, weak, and inane. A sane society would fix this mess.

  35. No doubt, fighting over ego and turf while our country lacks decent primary care is a stupid way to spend time. Personally, I lay the blame for us even needing to have these arguments at the feet of the medical education system. Medical schools, by their admissions policies and pervasive attitudes that undermine primary care, have played a big role in whittling our numbers down to this vulnerable spot.
    What I object to, however, is the automatic assumption that more NP’s equals more primary care. If you look at the trends over the past 10 years in the production of NP and PA’s, total numbers have gone up 34%, but the number actually doing primary care has gone down by 28%.
    http://www.ruralmedicaleducation.org
    How exactly does independent practice or even boosting the production of NP’s change this trend?
    If you want a versatile, cost effective primary care workforce that has the skills and training to handle undifferentiated medical problems in any setting and will remain generalists for their entire career, then what you want are family physicians. And if those family docs are working in teams with NP’s and PA’s in a patient centered medical home with an emphasis on care coordination and prevention, then we’ll have the supercharged primary care we need to make a dent in the cost of American healthcare.

  36. I was very surprised to learn that you can get a Nurse Practitioner (NP) Degree on-line. (Google it for yourself). There are a number of these programs available. How can I as a patient determine how well my NP was trained? Are these on-line courses rigorous enough? Who decides? Why can’t we just train physicians the same way as nurse practitioners, pay them the same and save lots of money. Are physicians wasting time training for so many years longer? Why is it so difficult to get into medical school? Do we really need to give such weight to high intelligence and accomplishments/ambition in the selection process. Does exposure during medical school and residency to the rare and complicated patients in the academic medical centers really matter? Do we need to preserve rigorous standards to insure that physicians are well trained? If we allow NPs to take over the role of physicians, than why have both training tracks, with the physician track being so much longer and costlier?
    I think this whole evolution of Nurse Practitioners has suddenly accelerated due to the diminishing numbers of primary care physicians, and due to the escalating costs of health care (the two factors are interrelated). Medical students are avoiding primary care, and some primary care providers have left primary care for multiple reasons, including the following:
    1) Increasing uncomponsated work put upon them by the government and insurance companies. I call it “Mother May I Medicine” as in Mother may I order an MRI, Mother may I prescribe this medicine. This “Mother May I” leads to filling out prior authorization forms, appeals, and other paperwork that takes the physician away from patient care and leads to frustrations and a less efficient practice.
    2) Decreasing fees, that have not kept up with raising practice costs leading to a treadmill pace to try to keep revenue up. (Makes it more difficult to pay off high educational expenses)
    3) Fear of litigation. There was a time when a primary care physician would invest considerable time working up undiagnosed symptoms, such as chest pain, rather than send them off to a specialist, or order expensive CYA tests. Now because of factor #2 (working faster with less time per patient) and fear of malpractice litigation (Attorney: So Dr. Jones didn’t you delay the diagnosis by not ordering the MRI on the first day you saw Mrs. Smith?), primary care physicians are resorting to playing traffic cop and directing the sign or symptom to the most appropriate specialist. I do agree much of the traffic cop role could be delegated to a NP. But shouldn’t we expect more from our primary care physicians.
    4) Primary care providers are growing ever more demoralized from #1-3 above. Allowing nurse practitioners to ursurp their position will lead to a greater dearth of primary care physicians, with the exception of Boutique practices where they can avoid #1-4 above and provide their services to those who value all that they offer.
    If I were king, I would initiate tort reform and pay primary care physicians to use their thorough training and keep patients out of the specialists office as appropriate, and minimize the use/cost of CYA testing. Limit the unnecessary paperwork so they have more time to spend with patients and be more thorough (get off the treadmill). Make the practice of primary care medicine attractive to students as it once was. Instead. I am afraid, we may seek another, perhaps easier solution and turn primary care over to less well trained NPs in an effort to lower costs.
    Reflect on what will likely happen to the physician primary care tract in this country if one can take a less selective, less rigorous, and less costly tract to get the same job. Whatever changes we make in our health care system as we wrestle with the unsustainable growing costs, please keep this question in mind: How can we best preserve high quality compassionate care for each and every patient.
    Sorry for this diatribe, but I am on vacation this week and don’t usually have much time to share my views on the health care blogs.

  37. NPs will find quick adaoption in the employer clinic setting. We are telling all of our clients they need to start planning for a shortage in primary care capacity and the best way to do that is employee them directly. For wellness and treatment of minor illness and injury there is no reason to pay for a doctor.
    It will be critical to make sure the system is designed so NPs don’t feel any pressure to treat beyound their ability

  38. If RNs want to practice medicine — become PAs.
    There is no place for nursing in medicine. Anyone who has actually studied health care’s many dimensions knows that.
    Medicine is about dealing with severe issues at hand.
    Nursing is pre-medical and post-medical.
    My God — would some of the writers here, please read about health care? And try to understand what they read?
    Writing all these corrections is like teaching MESS-iah about bankruptcy — tedious, unrewarding and, ultimately, a useless exercise.

  39. As an MD who works in clinic with 3 MD’s (all board certified in IM), 2 NP’s and 1 PA- I am very pro NP/PA
    90 -95% of what I do they can do – but it is that last 5% of knowing what to do and how that they turn to me for-. We work well together. But that year as an intern and 2 years as a resident are far more strenuous and instructive than the NP training. Some NP programs are mostly online courses! I have known some NP’s who had God complex as bad as some physicians. I am for NP’s working autonomously -but I would like a more rigorous training (like a 1 year internship- on the hospital wards)and certification program. But the move is inevitable- Physicians should be training to manage the team- the PCP is dead-

  40. When are we going to stop equating cheaper with lower quality in health care?
    This is a very good overview of a complex issue. I understand physician’s fear and anxiety over this one. Yet once again the physicians clinging to thier centuries old craft model has contributed to this situation. The answer is not physicians versus NP’s. The answer is in identifying the model(s) of medicine that best meets the needs of patients and then organizing around that. We need both professions, but not necessarily the way they are organized or the way they practice today. And, as they say in the medical home initiatives, you want each practicing at the top of their license. If we organize around the patient instead of the profession I believe we get better care, happier professionals and guess what? It will cost less.

  41. I like my good friend and family doctor’s take on this. In the end, America will choose soley on cost. Most will eat at McDonalds for the 99 cent burger instead of the $7.99 charged at a good restaurant. Why is Wal-Mart the biggest company in the history of mankind? Cheap sells!
    It’s not saying that all NP’s deliver poor care, they do not, but they do provide cheap care. Not all doctors provide “better” care. There are many doctors that one would not send a mangey dog to. But looking at the forest instead of the trees, doctors indeed do go to med school and residency and NP’s do not.
    He spent $250,000 and 11 years of his life to become a doctor. NP’s spend less time and less money. If this happens, he can foresee all people who go to med school going into specialty medicine. Why go through all that when one could do the same thing in less time for less money?

  42. Yeah, nurse Punxkkklwwzlllati, I’ve got some good news and some bad news. Good news is, you’re now a “doctor”. Bad news, I’ll need your next three months pay to cover your malpractice insurance this year and every year. But don’t worry, cause we’re getting reimbursed 10% more than before. It’s too bad you don’t have any ownership in how we allocate that extra 10%. Just keep doing your “doctorin” thing, when you’re done with those bed pans.
    ps, Sorry, you can’t wear those comfortable shoes anymore.
    LD

  43. What about PAs?
    How do 140 PA programs, just disappear?
    Are we on “Lost?”
    ////////////
    I’ve written extensively on clinics staffed by nurse practitioners.

  44. I’ve written extensively on clinics staffed by nurse practitioners.
    There are several factors worth considering. I believe physician objections are partly based on self-interest. Many doctors employ NPs in their practices and, as such, gain financially from their work. Because of this, some physicians would rather not have to compete with NPs (or pay them more because NPs’ increased options).
    Another point is that would-be physicians have largely abandon primary care as a profession. The AMA reports that only about 2% of medical students plan to enter primary care internal medicine. I realize physicians’ huge investment in education makes them want to protect their turf from less costly (and less indebted) competitors. But protectionism is not in consumers’ or patients’ best interest.
    Some patients would never dream of seeing any provider but an MD or DO. Others might opt for the convenience (or cost savings) of a NP. It should ultimately be up to patients to decide rather than permit medical societies to maintain barriers to completion (and barriers to access for that matter).

  45. ” .. What do you think is cheaper ..”
    This makes absolutely no sense, whatsoever.
    Ever been on the business-end of a medical-malpractice lawsuit?
    Health care professionals who have will never, ever talk that way.
    //////////////////////////
    ” .. a PCP recommending Tumms and a change in diet and exercise, or a referral to a gastroenterologist, to rule out weird stuff, right off the bat? A pediatrician spending time with mom explaining ear infections and maybe treating with cheap generics, or a referral to an ENT who is going to put tubes in for no good reason? A pediatrician ordering a 2D echo and EKG for a murmur, looking at the results and telling mom that all is well, or a referral to a cardiologist who will do the exact same thing for 3 times the cost?

  46. incohate,
    What do you think is cheaper, a PCP recommending Tumms and a change in diet and exercise, or a referral to a gastroenterologist, to rule out weird stuff, right off the bat? A pediatrician spending time with mom explaining ear infections and maybe treating with cheap generics, or a referral to an ENT who is going to put tubes in for no good reason? A pediatrician ordering a 2D echo and EKG for a murmur, looking at the results and telling mom that all is well, or a referral to a cardiologist who will do the exact same thing for 3 times the cost?
    As to the solo docs, why should we assume that their data is in silos? HIT can break, and will break all these silos, so care can be coordinated properly by the medical home. And what do you think is cheaper, treating your seasonal allergies at Mayo, or having Dr. Welby do it?

  47. FATAL FLAWS
    ” .. Medical evidence that NPs offer as good or better care threatens some physicians.”
    The writer is obviously confused. What are the NPs doing — medicine or nursing?
    Journalism 101. Try it.
    And imagine the patients trying to figure it out this kind of muddled thinking.
    Also missing — the 140 PHYSICIAN ASSISTANT programs are mysteriously missing from article.
    Why?
    Does the writer understand medicine and nursing?
    Obviously not. Pity.

  48. Margalit wrote:

    I think this would be a mistake. We should do exactly the opposite. We should remove the volume incentive completely, and financially reward primary care physicians for providing actual medical care.

    Great plan Margalit, and we should do so – just as soon as we accumulate more information that jacking up pay for more-intensive primary care (the sort you seem to be proposing) actually commensurately improves health, long-term.
    You’re on more solid footing here

    A solo doc, plus an NP could very well serve as a very effective medical home

    but not a whole lot firmer; a yearning for the Dr. Welby of yore is simply incongruent with what little evidence there is regarding the merits of integrated practice. “Integrated” does not imply “Kaiser-sized” practices, but a vision of expanded ranks of solo flyers, merrily siloing their patients’ health data, is not a future the evidence points towards.

  49. I have a problem with the logic here.
    Yes, primary care has been sabotaged by the perverse volume driven reimbursement system and many PCPs are not utilizing their full abilities to practice medicine. Instead they refer to specialists for almost everything. It doesn’t make financial sense to do otherwise.
    So what we are saying here is that we should accept this model of care, where the primary care provider is merely a coordinator or a triage nurse, and therefore relegate primary care to a lower paid resource.
    I think this would be a mistake. We should do exactly the opposite. We should remove the volume incentive completely, and financially reward primary care physicians for providing actual medical care. I don’t see how we lower cost of care without reducing the specialist to primary care ratio significantly. Replacing primary care physicians with nurses will drastically increase the ratio instead.
    All that said, NPs are highly qualified trained professionals and should absolutely play significant roles in medical home models, which I believe are the optimal solution to both cost and quality of care, and not just for the poor.
    Medical homes, by definition, will have to do lots of coordination, education, follow up and provide high availability. NPs in partnership with physicians could be the backbone of such organizations, and by the way, they need not be multi-specialty large enterprises. A solo doc, plus an NP could very well serve as a very effective medical home. Probably as effective as the much praised, but impossible to widely replicate, centers of excellence, and definitely more cost effective.

  50. This is a tough one. (Full disclosure: I only skimmed Maggie’s very long and small print post.) Like anywhere, there are NP’s who are good and therefore better than bad or lazy docs, and then there is the converse. I would say relying on NP’s for a primary diagnosis might not be the best idea, since they have a more circumscribed education in what the diagnostic possibilities are. But I agree they seem to provide more of what patients want/need in terms of spending time, listening and answering questions. (A provocative question: is this because the majority of them are women?) And certainly they can equal docs in follow up visits and continuing care.
    The same question pertains in many other specialties, like ophthalmology, oral surgery/ENT, etc. In my own specialty of pathology, there has been a trend toward having certified Pathology Assistants examine the gross specimens from surgery in place of pathologists. The pathologists love it because many of them were poorly trained in gross pathology and regard it as “scut work”, preferring to spend time looking at the microscopic slides. My problem was (and is): if a PA misses the breast cancer in the gross specimen, then it will never appear on the slide in the first place.
    The other side of this is: if the pathologist is poorly trained in gross pathology, then maybe the PA is better at it anyway.
    The same pertains to NP’s and primary care. It’s all in the scope of training and level of conscientiousness.

  51. If there wasn’t such an irrational reward given to procedural medicine in our health “system’s” econometrics, there probably wouldn’t be so much push-back against indipendent practice by NPs.
    I’ve had the fortune to work with independent NPs who filled key rolls in their community’s healthcare “web”, and certainl we need more practioner hoursepower in primary care throughout the country.
    NPs aren’t the same as MDs, and Maggie’s blog does an excellent job of delineating these macro-differences. The primary care needs of patients varry considerably as well, and for many patients the teaching tradition of NPs may be more appropriate than the directoral role of physicians (to oversimplify absurdly).

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