Appropriate Role for NPs

[Law2Doc]

as you well know a dpa still needs a supervising physician and is in no way equivalent to an md/do. ...

Today this is true. But next week...
Erosion is a dangerous thing. It seems small on day one. But over time it can turn a mountain into a crater. Lawyers get it. They sued paralegals, realtors, accountants over relatively small potatoes -- odd quasi-legal form-related tasks that these ancillary professionals wanted to do unsupervised (things like corporate documentation, title work), that most lawyers don't even consider bread and butter income or particularly interesting tasks. But it was assumed (rightly) that the erosion wasn't going to stop there. You give an inch you lose a mile. So you have to draw your line in the sand early on. As a result lawyers were never really under siege the way the primary care physician functions are today. Physicians need to do this.

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[Taurus]

In this presidential election, Barack Obama has shown the country how powerful the internet can be to reach out and spread his message. I believe that sites like SDN is the first step. We can start to turn the tide by educating our future colleagues about what's happening to their profession. I'm always surprised by how many physicians are completely oblivious to what's happening. It's unfortunate that medical schools and residencies focus so much on the medicine that they don't talk about the non-medical aspects of healthcare that probably will have as much or more impact on the daily lives of physicians. Informing current and future physicians of the dire future unless we unite and make a stand is what keeps bringing me back to SDN.

 

[Long Dong]

In this presidential election, Barack Obama has shown the country how powerful the internet can be to reach out and spread his message. I believe that sites like SDN is the first step. We can start to turn the tide by educating our future colleagues about what's happening to their profession. I'm always surprised by how many physicians are completely oblivious to what's happening. It's unfortunate that medical schools and residencies focus so much on the medicine that they don't talk about the non-medical aspects of healthcare that probably will have as much or more impact on the daily lives of physicians. Informing current and future physicians of the dire future unless we unite and make a stand is what keeps bringing me back to SDN.

Word, I nominate Law2Doc since he/she is a lawyer. Get a petition together I'm signing it and then forwarding to every doc I know. Let's do this.

 

[core0]

I think there are a lot of interesting discussion concepts badly intertwined in this thread. In terms of teaching, I think it's silly to worry about a person's station. If someone knows more than you, then they can be your teacher. So a PA or NP with years of experience ought to be able to teach a resident fresh out of med school. The student will absolutely surpass the teacher in this situation given the ultimate position the resident will achieve, but until that happens, there isn't a good reason a mid-level ancillary professional couldn't teach a higher level professional in training. Heck, an attending can learn from an intern if the intern knows more about a certain topic or procedure. It's substance over form.

As for NP/PAs "stealing" procedures, this happens a lot at hospitals where you have to do a number of supervised procedures before you are "signed off" to do them. In a hospital with a residency program, I think the resident, the person the government is effectively paying the hospital to train, needs to get first crack at it.

I agree that the resident should get the first crack. The issue I see (although infrequently where I am) is that some attendings are not into the teaching aspect. They want to get done and will give procedure to an NP/PA who has done a bunch and can do them fast rather than take the time to teach the resident (or let them get practice). It goes along with what Tired is talking about. The attendings don't want to do their primary job which is instructing residents.

Finally, the basic concept of NPs/PAs acting autonomously are being marketed to patients as the equivalent of physicians represents a huge misstep by the medical profession. Physicians need to organize and lobby to set limits as to what ancillary professions should be allowed to do and not do. There is huge encroachment going on, there are ancillary professionals acting as if they are physicians, some even holding themselves out as doctors. In law, similar encroachments have been attempted by paralegals, realtors, accountants. In each case lawyers fought tooth and nail and very specific legislative boundaries as to what constitutes "the unauthorized practice of law" now exist, into which ancillary professionals dare not treat or risk huge lawsuits and penalties. Physicians could do likewise, but thus far are poorly organized and their organizations even more poorly funded. This needs to be fixed, or you will see gradual erosion and blurring of physician roles, additional encroachment, and more and more non-med school trained individuals calling themselves "doctor". The high costs of healthcare make these ancillary professionals an easy fix in the government's eyes, so doctors actually need to move fast to shut this down.

You need to separate the NP and PA here. PAs are regulated under the BOM. While there is some variation most state PA practice acts place two limitations on PA scope of practice. PAs are not allowed to do anything their SP does not allow them to do and PAs are not allowed to do anything that their SP cannot do. So the autonomy that you see is PA practice is permitted by their supervising physician. Ideally it should be a partnership where the physician knows the limits of a given PAs skill set and allows sufficient autonomy to maximize efficiency in a medical practice. Having participated in modifying PA practice acts in two states, I can tell you that most requests for decreased restrictions come from the physicians that employ PAs.

NP scope and autonomy is a separate issue.

David Carpenter, PA-C

 

[Law2Doc]

You need to separate the NP and PA here. PAs are regulated under the BOM. While there is some variation most state PA practice acts place two limitations on PA scope of practice. PAs are not allowed to do anything their SP does not allow them to do and PAs are not allowed to do anything that their SP cannot do. So the autonomy that you see is PA practice is permitted by their supervising physician. Ideally it should be a partnership where the physician knows the limits of a given PAs skill set and allows sufficient autonomy to maximize efficiency in a medical practice. Having participated in modifying PA practice acts in two states, I can tell you that most requests for decreased restrictions come from the physicians that employ PAs.

NP scope and autonomy is a separate issue.

David Carpenter, PA-C

While I agree that NP and PA are not similarly situated, nor have their respective "grabs" at autonomy been identical, I think the goal of physicians should be to have bright line distinctions of what non-physicians can and cannot do, regardless of who we are talking about. Both sets of ancillary professionals have made inroads into activities that have traditionally been that of primary care physicians, though the approaches have been different.

But it's really not that different than in law when paralegals and accountants each made their respective runs at certain tasks that were traditionally the practice of law. Sure they are differently situated and their levels of education are quite different (accountants have significantly more schooling and licensing requirements than paralegals, generally), and paralegals traditionally had been required to work under supervising attorneys. But without litigation and subsequent legislation both sets of individuals would have carved out autonomy and practices over time quite different than they are today.

If medicine sets out fixed rules saying -- this is the practice of medicine and nobody without a license can do these tasks unsupervised, or hold themselves out as "doctor" in a healthcare setting, and anyone who tries gets sued into oblivion -- then the profession will be safe, and PA and NP roles will be adjusted to work within those confines accordingly (and appropriately, based on their levels of training, IMHO). There will be less risk of erosion because the borders will be clear and penalties will exist for those who step across. And less confusion for patients who really truly don't know the difference between the various people wearing white coats, but do, in fact, assume that anyone who is the primary person taking care of them when they go to a hospital or "doctor's" office has the kind of schooling and training provided in medical school and residency.

To tell a patient that X is "just as good" or only 1 year difference, or whatever receptionists/offices mentioned above in this thread are saying, is the kind of misrepresentation that needs to be eliminated. And ancillary professions creating their own doctorates so they can call themselves doctors in the office setting is another kind of fraud on patients that needs to be eliminated. Finally, there are plenty of tasks that are traditionally done by physicians that shouldn't be done autonomously by non-physician professionals (not because they can't, but because these are traditionally physician roles), that really need to be protected, because this represents the kind of erosion that results in a slippery slope. Once an ancillary person can do X, it's only a small step before they can also do Y, and so on. (And they can do it cheaper, which sounds better to government representative, insurers and self-paying patients, because they didn't have all that expensive schooling and training a physician had. But that sort of misses the point of the schooling and training, which isn't just an exercise, but has good reason).

 

[Taurus]

If medicine sets out fixed rules saying -- this is the practice of medicine and nobody without a license can do these tasks unsupervised, or hold themselves out as "doctor" in a healthcare setting, and anyone who tries gets sued into oblivion -- then the profession will be safe, and PA and NP roles will be adjusted to work within those confines accordingly (and appropriately, based on their levels of training, IMHO). There will be less risk of erosion because the borders will be clear and penalties will exist for those who step across. And less confusion for patients who really truly don't know the difference between the various people wearing white coats, but do, in fact, assume that anyone who is the primary person taking care of them when they go to a hospital or "doctor's" office has the kind of schooling and training provided in medical school and residency.

To tell a patient that X is "just as good" or only 1 year difference, or whatever receptionists/offices mentioned above in this thread are saying, is the kind of misrepresentation that needs to be eliminated. And ancillary professions creating their own doctorates so they can call themselves doctors in the office setting is another kind of fraud on patients that needs to be eliminated. Finally, there are plenty of tasks that are traditionally done by physicians that shouldn't be done autonomously by non-physician professionals (not because they can't, but because these are traditionally physician roles), that really need to be protected, because this represents the kind of erosion that results in a slippery slope. Once an ancillary person can do X, it's only a small step before they can also do Y, and so on. (And they can do it cheaper, which sounds better to government representative, insurers and self-paying patients, because they didn't have all that expensive schooling and training a physician had. But that sort of misses the point of the schooling and training, which isn't just an exercise, but has good reason).

I second the motion that Law2Doc should take a leadership role in medicine or run for political office. We need more good people like him with the experience and vision to take medicine into the future.

An important difference between medicine and law in this country is that the public is not demanding more lawyers but they are always complaining that there aren't enough doctors. With such demand and the politicians not wanting to see their voters sick and dying, the lawmakers voted to expand scope to these non-physician groups and unfortunately the doctors couldn't do much about it.

There is no going back to the days when doctors were doctors and nurses were nurses and their roles were clearly defined. It's sickening to me to see so much overlap of roles and the power grab that goes on by the newly empowered groups to get even more. It's about greed. As Law2Doc said, we need to clearly define boundaries between physician and non-physician groups, much like the boundary between surgeons and non-surgeons. I never hear nurses talk about how they have a "right" to practice surgery independently, while I hear that language frequently about primary care, even cardiology.

While we probably can't take back the new medical privileges that have been bestowed on these non-physician groups, I think that the most important thing we can do now is determine how medicine is regulated in these groups. I firmly believe that state boards of medicines should be able to regulate how medicine is performed by any non-physician groups. The BOM's have the expertise to establish training guidelines and have the mechanisms to monitor and discipline misconduct. What sense does it make to have state boards of nursing regulate NP's when NP's practice medicine? If the BON's can't even regulate their own nurses, what confidence do the public have that NP's have the same professional standards as physicians? These are the issues that the public need to know and that lawmakers need to correct.

regulators acted belatedly or not at all, even when explicitly told that nurses had committed serious crimes. Some were handed renewals after reporting their own felonies to the bureau.​

These groups can be regulated jointly with their board and BOM or completely under BOM, for such groups like NP's since they don't practice nursing at all anymore.

 

[siempre595]

MacGuyver, is that you?


No, nevermind....this thread lacks the tone of desperation and insecurity....

Ugh, no, I've never been someone named MacGuyver, I've always had this name....

 

[8744]

But it's not about you specifically, and you know that.

We go to residency to learn to be specialty physicians, and it only makes sense to have specialty physicians teach us.

Programs that have PAs precept residents (ie - make the final call on diagnosis and management decisions) don't put caveats like, "PAs must have 22 years experience and hold X number of certifications".

When you did inpatient care rotations in PA school, did NPs precept you? How would you have felt if they had?

Word. I'd probably quit a program that had PAs precept doctors on the basis that the program is too lazy and poorly run to schedule attending phyiscians to do it. Not a good message to send to the residents.

 

[mig26x]

Word. I'd probably quit a program that had PAs precept doctors on the basis that the program is too lazy and poorly run to schedule attending phyiscians to do it. Not a good message to send to the residents.

100% with you. Any program that has residents precept with anyone that is not an attending is putting that resident education and formation as a professional in jeopardy and also the patient health in jeopardy.

If interns cant even precept with a senior resident a case (where the senior has the final say) why should they precept the case with someone that hasnt even gone through MEDICAL school?

In my program even fellows need the attending "permission" to send someone home. I had a case like that this past week. guy with CP r/o two trops negative and no cardiovascular risk factors, we sent the guy home the same day but before that the fellow had to notify an attending what was our plan and the attending to be ok with it.

 

[8744]

100% with you. Any program that has residents precept with anyone that is not an attending is putting that resident education and formation as a professional in jeopardy and also the patient health in jeopardy.

If interns cant even precept with a senior resident a case (where the senior has the final say) why should they precept the case with someone that hasnt even gone through MEDICAL school?

In my program even fellows need the attending "permission" to send someone home. I had a case like that this past week. guy with CP r/o two trops negative and no cardiovascular risk factors, we sent the guy home the same day but before that the fellow had to notify an attending what was our plan and the attending to be ok with it.

Exactly. I'm a PGY-4 and a licensed physician in the Great State of Louisiana (where I will practice after I graduate residency) and I still have to staff my patients with my attending. The junior residents ask for my advice of course and I help them out but they don't staff their patients with me. I'm not complaining but there is no way I'm going to staff a patient with someone who isn't an attending physician. It's kind of insulting when you think about it.

The ridiculous thing is that PAs and NPs are allowed to practice independently but my program prohibits me from working as a phyisician outside of my hospital even if I have an unrestricted state license (I have a resident license in this state). Obviously there are liability concerns secondary to my lack of a complete medical education, concerns of which I am in full agreement as it relates to my specialty.