Broadening the Scope of Nursing Practice (NEJM)

[cbrons]

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If you have NEJM: This Week on your iPad/iPhone you might have seen the article entitled, Broadening the Scope of Nursing Practice.

Excerpt:

Evidence from many studies indicates that primary care services, such as wellness and prevention services, diagnosis and management of many common uncomplicated acute illnesses, and management of chronic diseases such as diabetes can be provided by nurse practitioners at least as safely and effectively as by physicians.1 After reviewing the issue, an Institute of Medicine (IOM) panel recently reiterated this conclusion and called for expansion of nurses' scope of practice in primary care.2

Link: http://www.nejm.org/doi/pdf/10.1056/NEJMp1012121



Notes for the TIHC forum:

Question 1: What are your thoughts?
Question 2: Is this the inevitable future?
Question 3: Where is Taurus? DbDan (who found this) didn't scoop him did he? 🙂

 

[hrandani]

Well I'm glad I got straightened out. Here I was thinking the whole point of having highly educated medical practitioners is to catch the complicated diseases that present uncommonly and thereby catch diseases before they become a much more serious problem.

In the future I'll just call my grandmother for medical advice.

On a serious note this is a war that is going to be fought in the realm of public opinion. The economics of the situation are pretty clear. It's part of the consequences of having the system set up the way we do, as opposed to other countries which do not have that many obstacles to becoming a physician. By having more expensive medical care you end up inadvertently making medical care more expensive by treating more advanced disease. People don't like going to doctors when they have to wait weeks to make an appointment, hours at the office, fifteen short minutes with an irritated GP and have to pay hundreds of dollars for the privilege.

 

[cardiotruth]

A good retort: Nurses' Scope of Practice

 

[DbDan]

A good retort: Nurses' Scope of Practice

Definitely a good analysis by those two physicians. 👍

Didn't see those when I found this article originally. They basically addressed everything that I thought as I read the initial article.

 

[pingouin]

moving to topics in healthcare

 

[Lokhtar]

It seems to me that this is inevitable with the current system of primary care that we have. Primary Care physicians aren't really allowed to do everything their training enables them to do, so all too often they are referring to specialists cases which they could handle themselves.

I would personally like to see a strengthening of primary care, with better reimbursement relative to specialists but also, and perhaps more importantly, more responsibility.

 

[xanthomondo]

moving to topics in healthcare

Yay, so that med students who don't know much about what's going on with healthcare will continue to stay that way!

 

[xanthomondo]

That's fine, if they think NP=MD, they should give everyone who's about to get Obamacare access to NPs only. Stock them in the ED, the office, and why not even the OR.

We'll see how equal they are.

 

[cbrons]

Sad that this got moved out of the allo forum, there are not as many responses as I had hoped.

 

[JaggerPlate]

Kudos to the AOA, AMA, AAFP (and whoever else) for writing that rebuttal letter. However, I'm really sick of this bull**** propagating into respectable sources - the IOM and now the NEJM?

Make no mistake, the militant DNPs have made this into a war on many fronts, and we need to fight it on the PR level, in the hospitals themselves, and by rejecting these providers in the field. It's about patient clarity/safety, and we're all well aware that these laughable studies are flawed to the point where conclusions regarding this important aspect are inconclusive at best and dangerous at worse.

 

[bronx43]

It seems to me that this is inevitable with the current system of primary care that we have. Primary Care physicians aren't really allowed to do everything their training enables them to do, so all too often they are referring to specialists cases which they could handle themselves.

I would personally like to see a strengthening of primary care, with better reimbursement relative to specialists but also, and perhaps more importantly, more responsibility.

Bingo. The key point in this whole exchange is the fact that the system is far too specialist heavy, which inevitably drives up cost without there being a proportional improvement in outcome. It's painfully obvious that there are a glut of things currently in primary care that can very easily be performed by nurse practitioners without a noticeable drop off in quality of delivery or outcomes. In all honesty, it's pretty myopic for family practitioners to resist "encroachment" of NPs, when such a trend can allow for them to take on more of the responsibility that is currently being transferred to the specialists. In essence, broadening the scope of NP would inevitably lead to a corresponding broadening of the scope of family medicine - since FM is in a unique position of controlling patient flow.

 

[Kaustikos]

Sad that this got moved out of the allo forum, there are not as many responses as I had hoped.

That means we can't say what we really feel about the issue...or we'll keep lambasted by other groups

This paper is a joke and DNP =/= MD



/RUN AWAAAAAAAAAY

 

[JaggerPlate]

Bingo. The key point in this whole exchange is the fact that the system is far too specialist heavy, which inevitably drives up cost without there being a proportional improvement in outcome. It's painfully obvious that there are a glut of things currently in primary care that can very easily be performed by nurse practitioners without a noticeable drop off in quality of delivery or outcomes. In all honesty, it's pretty myopic for family practitioners to resist "encroachment" of NPs, when such a trend can allow for them to take on more of the responsibility that is currently being transferred to the specialists. In essence, broadening the scope of NP would inevitably lead to a corresponding broadening of the scope of family medicine - since FM is in a unique position of controlling patient flow.

The problem is that the DNPs have absolutely 0 interest in stopping at FP, nor do they believe their knowledge should limit them to the 'routine.' If you need any proof, look at the DNP 'residency' programs in fields like dermatology. Look at the number of DNP/NPs pushing for more involvement in cardiology, critical care, etc. It's not myopic for FPs (or all physicians for that matter) to stop NP encroachment into primary care because they have no interest in staying in PC fields, nor is ANY specialty field safe from encroachment (unless the trend is stopped NOW).

Even if you believe that they can handle a majority of the 'horseys,' their advancement into primary care is a facade that enables them to get a foot in the door and use it as a springboard into the better paying, more specialized areas of medicine. Truthfully, I don't think detecting skin cancers in dermatology or handling complex cases in anesthesiology is anything routine, but it's where the NPs are headed (or are already at) as we speak. If PC providers really want someone to handle the routine while they focus on more difficult cases or areas of the practice that could really increase 'specialized' type reimbursement, hire a PA. These individuals are far better trained and aren't looking to practice medicine without a license and endanger patients.

 

[cbrons]

The problem is that the DNPs have absolutely 0 interest in stopping at FP, nor do they believe their knowledge should limit them to the 'routine.' If you need any proof, look at the DNP 'residency' programs in fields like dermatology. Look at the number of DNP/NPs pushing for more involvement in cardiology, critical care, etc.

When you give an inch, you lose a mile. A lot of inches have been given to the nursing lobbies and a lot of miles have been lost as a result.

Now, as to the notion that NPs can substitute physicians in the primary care arena, I disagree. It is erroneous to believe that family medicine physicians are not specialists in their own right. In fact, an argument could be made that it is the most dangerous to cede primary care entirely to nurses because it is at the level of the PCP that key determinations are made in how/whether to treat/transfer a patient.

 

[Downbytheicu]

This might sound trite or inconsequential, but I believe that semantics do matter, and a big step that the AMA and physicians can make is to drop the moniker of "Provider", or even "primary care". They are words made up by bureaucrats and do not adequately describe what physicians do. Additionally, by using the word "provider" it opens it up for multiple professions to lay claims to the same name, which lends itself to an equality that may not be merited. It's difficult to have a hierarchy within a word. To many people, a PCP is a PCP regardless of whether it is a family practitioner, an internist, a NP, a naturopath, or a chiropracter. But by embracing the word, we are equating ourselves with these other groups.
Just my two cents.

 

[engineeredout]

I like this specifically

Nurses tend
to move from more restrictive to
less restrictive states, and from
primary to specialist care, with
a resulting loss of access to care
for patients.

So what it boils down to is nurses are not trying to look to fill the primary care gaps that are out there. They want to be specialists just as much as many physicians do, with the pay and responsibility to go with it. These advance practice nurses want to be physicians.

 

[JaggerPlate]

I like this specifically

So what it boils down to is nurses are not trying to look to fill the primary care gaps that are out there. They want to be specialists just as much as many physicians do, with the pay and responsibility to go with it. These advance practice nurses want to be physicians.

I think their whole 'filling a crucial primary care gap' lie died for me the day I saw the University of SOUTH FLORIDA 'nursing dermatology residency' with cosmetic components and an accompanying video where 'Dr' Debra Shelby introduced herself as the 'residency director of the dermatology program at USF' and proceeded explaining the program (she's a DNP). To me, this doesn't scream - selfless practitioner who just wants to help those who need it.

 

[morning]

That's fine, if they think NP=MD, they should give everyone who's about to get Obamacare access to NPs only. Stock them in the ED, the office, and why not even the OR.

We'll see how equal they are.

WTF does "who's about to get Obamacare" mean?