Comment on np's in fp journal...thoughts?

[deleted6669]

Jeff†Susman,MD
Editor-in-Chief
[email protected]

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.
Why do I call for such a fundamental change in policy? First, because it’s the reality.
In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:
Nurses should practice to the full extent of their education and training.
Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training.
Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care.
Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.
Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition.
As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisioning the future of health care.
The Journal Of Family Practice ©2010 Quadrant HealthCom Inc.

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[deleted87716]

Everyone's entitled to their opinion.

 

[JackADeli]

...Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates...

That much I agree in general terms accross specialties.

However, it is fundamentally dishonest to pose full and/or equal partnership between two parties with such a discrepancy between the individuals' capacity. There is clearly treatments that are simple. However, patients pay a physician fee for the overall volume of training and knowledge... especially when things go from simple to complicated.

i.e. A patient coming in for BP management. It sounds simple. We can say provider "A" does the same as provider "B". However, should they be paid the same if one provider is trained and capable of taking the treatment/s to the next step and the other is not? It is similar to the "global period" argument of the other thread. The patient pays their trusted primary care physician and trusts him/her not just because of the care they provide but because of the care they are able to provide and/or the unknown diagnosis he/she can make based on no less then 7 years of graduate education (i.e. 4med-school & 3+ residency).

Patients want excellence and perfection. There should be no short cut to care. Four years of medical school and three years of 60-80hrs/wk clinical training is a far cry from the alternative...."full partner".

 

[JaggerPlate]

This guy must be French or something ... 'let's roll over and give up because it's probably going to happen anyway and it's a pain to stand up and fight for something we've all sacrificed years of our lives for.' Disgusting.

 

[deleted87716]

I find it somewhat ironic that he admonishes us for "clinging to the past," while simultaneously editing a journal that incorrectly refers to the specialty as "family practice" nearly seven years after the official name change to "family medicine."

I'm all for collaboration. What I'm opposed to is independent practice.

Independent practice will not solve our access problems as a nation any more than it has solved them in the states where it's already permitted.

 

[altap]

IMHO, the divide and conquer strategy being employed against physicians is working.

 

[deleted87716]

IMHO, the divide and conquer strategy being employed against physicians is working.

That actually isn't their strategy.

They're basing their arguments and lobbying efforts on the fear of an impending access crisis; essentially, scope expansion by legislation rather than competency.

Most physicians and physician advocacy groups are united in their opposition to independent NP practice, the occasional academic-with-a-bully-pulpit notwithstanding.

 

[JaggerPlate]

Most physicians and physician advocacy groups are united in their opposition to independent NP practice, the occasional academic-with-a-bully-pulpit notwithstanding.

YUPPPPP!!!

 

[JackADeli]

IMHO, the divide and conquer strategy being employed against physicians is working.

I think there is quite a bit of divide and conquer between physicians in different specialties in reference to healthcare reform in general. However, I don't see much division between any specialties in reference to mid-levels and their play for independence and/or "equality" status.

 

[MedicineDoc]

It is obviously a bad thing to allow people with much less training and lax educational requirements to practice medicine. There are much more stringent licensing requirements for veterinarians than nps and vet schools receive much better students!

 

[lowbudget]

What is there to have thoughts about?

Among the IOM's conclusions:
Nurses should practice to the full extent of their education and training.
Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Duh, no crap, that nurses should practice to the fullest extent of their education and training. Nobody wants to waste skills. That's not the problem. The problem I have is the actual education and training itself!

Duh, no crap, that nurses should achieve higher levels of education and training through an improved education system that promotes seemless academic progression. I am pro-smart nurses and anti-dumb nurses. I'm not hindering their education. My license is to practice medicine. Their license is to practice nursing. I want them to be the best nurses they can possibly be. The problem occurs when nurses try to practice medicine.

Duh, no crap, that nurses should be partners with doctors in redesigning health care. We should partner with information technology also to redesign health care, but you don't see computer scientists yelling and screaming about wanting to practice medicine.

Second, I believe our arguments against such a shift in policy don't hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training.
Indeed, the arguments family physicians make against APNs sound suspiciously like specialists' arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let's celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care.

I've used this argument before. But the more I think about it, the more I realize there's a critical nuance here. Gastroenterologists and family physicians are physicians. Nurse practitioners are not. My medical license is unrestricted; but the limits on what I do are determined by the risk of malpractice and the risk of having that license taken away from me.

In our country, government does not regulate the practice of medicine (as a legal matter). The scope of our medical practice is limited by community standards and we are accountable to our patients for what a "reasonable" family physician in my community would do. We, as doctors, organize ourselves and create our own standards like board certifications and enforcement mechanisms that are accountable to the public (like the medical board), because the PUBLIC believes that physicians can best govern themselves than to be govern by a government where people don't have this specialized knowledge.

The nursing license is totally different. Only physicians may practice medicine. To my understanding, that's the legal basis for why we have licenses.

(Interesting little summary about the history of nursing license http://doh.sd.gov/boards/nursing/Documents/WhitePaperHistory2000.pdf)

Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.

The American public benefits when those who educated and trained to practice medicine fight to maintain a high standard for medical care. That's what our license calls for.

Think about it this way: I now have had 2 patient come to my office telling me that their moms are nurse practitioner and ask that I speak with them blah blah. Come to find out that these people are MA's, medical assistants with a <1 year certificate from community college. Not even an LVN/LPN.

What happens when MA's are being confused for NP's?

From my standpoint, yes, we all should "work together". But, no, we should not do away with distinctions. We carry distinctions because differences exist.

 

[altap]

We may disagree on what strategy they are employing against physicians but any physician that they recruit or that agrees with them in their quest for equivalency and then writes a piece like this, not just weakens, but wreaks havoc on the cause of physicians. This is a powerful propaganda.

 

[deleted87716]

This is a powerful propaganda.

Not really. It's one guy's opinion. Nothing more.

 

[MOHS_01]

Sounds to me like someone has been dipping into the anesthesia cart again... or is singing the party line in hopes of an anointed appointed position in some new healthcare bureau.

 

[DOtoCanada]

I just got a letter from my oncologist's office. One of the partners in the practice was interviewed in it saying that the new ARNP working in the office was a "wonderful addition" and that she was "fully capable of doing everything that we can." Why go to undergrad, medical school and six years of residency/fellowship when you can take two years of grad school on the internet. Ug. I found it insulting.

 

[JackADeli]

So we're trying to prevent them from getting this unrestricted license in the remaining states, right? What about the states that already gave it to them (some did, right?)? Is there anything else that can be done there or are physicians only focused on the states remaining?

The verbage needs to be used very judiciously. The way you pose your statement/question adds fuel to the fire and hurts what the real issue is.

"we" are not trying to prevent licensure. "we" are not trying to get licensure from other states retracted. We want them to get licensed... within the scope of their training. What we want is to assure patients get the best quality care from fully trained providers of said care. We want to ensure patients receive care from individuals practiceing within the scope of their training. We do not want patients, family members, politicians, etc... being fed deceptive misinformation that suggests a four year undergrad degree, followed by some additional textbook education, +/- online coursework, and a few hundred hours of clinical experience creates a healthcare provider equally qualified to someone that has a 4 year undergrad degree, intense 4 year graduate degree (MD/DO), and in most cases, at least 3 years of 60-80hrs/wk of intense clinical training that is tested yearly! Nurses and PAs are not the answer to increasing access to QUALITY primary care or any other specialty in medicine. They are part of the team and can help... but they are not cheap/short-cut "equal" replacements.

If we get drawn into verbage and emotional arguments that end with people thinking we are after the poor nurse... lives next door, or is my aunt, or is my mother, etc.... we loose. There are clear and very demonstratable differences in what goes into being a nurse/PA and what goes into being a unrestricted licensed physician. Those are the points that need to be allways focused on.... We need to eliminate the old "nurse is there to protect the patient from the doctor" or the "nurse is a patient advocate".

 

[JackADeli]

I thought my use of "unrestricted" made it clear what I was trying to say but I guess not. If there are differences and it puts patients at risk, should we just keep talking about what we "want" or do something about it ... like prevent it? To spell it out for you, I mean prevent UNRESTRICTED licensure to practice medicine.

sure, whatever. my point is not to get into a pissing match with you or anyone.

It is just very easy for the objectives to get distracted and that is how the politics accross all healthcare issues are going. I want RNs, NPs, DNPs, PAs to ALL get "unrestricted" licenses... that is unrestricted in so far as they practice within the scope of their actual training.

IMHO, the focus of the discussion should be the tangible facts. We should not get distracted with terminology that can be taken by some in lay public and political office to think we are turf warring or so called studies of equivalent outcomes or other such things. Then we will spend ages arguing minutia of the quality of studies, etc...

Instead, we should always, in every conversation avoid those items and simply put up a chart of actual training. That is ~objective. Every MD/DO that graduates and completes US licensing exams completes the same minimum requirements to sit for the US examinations. Every family medicine physician or other specialty that graduates from an accredited US residency completes the same minimum requirements. Put up the comparative bar graph of years or hours of clinical training, etc.... avoid getting drawn into the red herring arguments. Just put up the nice chart of side by side comparison and ask the question,
"are these two equally qualified, equally trained, etc, etc....? Please Mr/Mrs Repesentative/Senator you tell us? Because, if they are, stop funding medical schools and residencies and save lots and lots of money and just pay for the short courses...."

 

[JackADeli]

Jack, I just want to know if any effort by the medical majority is going into the states where the nursing lobby has already gained rights to practice independently or if the focus is solely on the states where they have not gained such rights yet.

I don't know....

My general impression is that most physicians in the med establishment function like sheep and go into a corner bleeting amongst themselves. I have watched it from med-school through residency. The general mentality is "don't be a complainer" and this usually results in "us" getting together and complaining amongst ourselves.

I have been less then impressed with any "organized" physician lobby effort. It came up in another thread, can't remember which, but if every physician put in $1K towards a unified lobby it would be one of the best funded. The problem is the "unified" aspect.

We spend so much time shooting ourselves in the foot. the average American believes the AMA is our representative/s. During the build-up to the healthcare reform bill, a handful of physicians got their white house white coats. We had weeks of medical-students being paraded on TV and elswhere talking about their great plans for community service and some even saying physicians are paid too much and it "should be about service".

IMHO, as a group, "we" are exceedingly divided and seem to go to great strides to keep our heads under the sand so as to prevent any ability to engage in reasonable conversation. Think about it, again said in numerous other threads & forums, how much of the business side of healthcare are you taught/do you learn in med-school? residency? practice? Most are taught nothing and learn little before going into practice. This can often mean that your first few years really are "paying your dues"... to the tune of 100's of thousands of dollars of hospital and industry profit through your acceptance of relative underpayment for your labors in your initial contracts...

So, getting back to independent mid-levels.... The debate should never have gotten this far. Simple and easy to understand graphic charts that even my HS drop out mechanic could understand should have quashed this movement a long time ago. Instead, head in sand and "disbelief" that "anyone" would ever allow such an insane idea. Except, the anyone is US. I don't know if some think they are too good to get involved in this minutia or presume the world understands and appreciates our value... Whatever it is, public education on mid-levels seems to be primarily via mid-levels and corporate folks... "we" have allowed the adversarial relationship with nursing to continue far too long. Since "we" physicians of the past threw fits and/or instruments now must bend over backwards to provide "restitution". Med-students are still coming through being taught, "be nice to the nurse or she will make your life hell, page you all night, etc, etc...". It's a mess and "we" need to just say enough is enough accross the board. Professionalism is at all levels. That means physicians do not act like jerks. It means physicians learn about the business and take active part and responsibility in the healthcare system. That means nurses act professional (i.e. stop with the excuses based on past misconduct of MD/DOs) and accept the limitations of training and work to their fullest extent of their training......

Yes, I get it that my reply encompasses alot of wide sweeping things. But, that is my point, we need to understand the past, the current, and the wider issues if we think we will address the individual issues..... These issues are all like dominos.

 

[FutureDoc4]

With friends like Dr. Susman, who needs enemies?

And they wonder why us medical students are only going to run further from primary care.

 

[leviathan]

I read a bunch of RNs complaining about how LPNs were starting to learn how to initiate IVs (*gasp*), among some other traditional RN tasks. They said the LPNs do not have enough education and therefore patient safety would be at risk.

I asked what they thought about the safety of NPs starting to assume some responsibilities of family physicians but didn't get an answer.

 

[deleted87716]

I just want to know if any effort by the medical majority is going into the states where the nursing lobby has already gained rights to practice independently or if the focus is solely on the states where they have not gained such rights yet.

Scope issues are dealt with at the state level.

 

[altap]

The us against them mentality among physicians should stop. Nurses know this all too well that is why they are taking advantage of this. Unite!

 

[Ypo.]

I find it somewhat ironic that he admonishes us for "clinging to the past," while simultaneously editing a journal that incorrectly refers to the specialty as "family practice" nearly seven years after the official name change to "family medicine."

I'm all for collaboration. What I'm opposed to is independent practice.

Independent practice will not solve our access problems as a nation any more than it has solved them in the states where it's already permitted.

Ditto. So far my experience has been that nurse practitioners should not practice independantly for patient safety and benefit. (no offence to NPs). I don't have any problem with increasing positions for NPs as long as they continue to work closely with physicians.

Honestly, I can see a clear difference between PAs and NPs in terms of their level of knowledge and expertise. In my experience they perform on par with a "weak family practitioner" (if that makes any sense). There are some that are on par with an average family physician. My husband sees one of those, actually. However, by and large I don't think you can compare a nurse's training to that of a physician.

I'm also concerned that this trend may have the effect of discouraging medical students from choosing FM as a specialty.

 

[deleted87716]

Blue, how about the medical majority in each state? Do you know if the fight for the highest quality patient care has ended in those states?

The general feeling amongst physicians in states where NPs have "independent" practice rights is that we shouldn't worry about it. It hasn't made much of a difference in those states. Few NPs actually WANT to be independent (they know their limitations, and don't want to shoulder the financial and liability burdens that go with it) and few want to work in underserved areas, for the same reasons as physicians.

 

[JaggerPlate]

I read a bunch of RNs complaining about how LPNs were starting to learn how to initiate IVs (*gasp*), among some other traditional RN tasks. They said the LPNs do not have enough education and therefore patient safety would be at risk.

I asked what they thought about the safety of NPs starting to assume some responsibilities of family physicians but didn't get an answer.

COUGH, COUGH ... ACKKK ... ACCCK ...

wheww, I'm sorry; I'm sorry! I just choked on the irony. Man, close call!

 

[deleted87716]

In the NEJM, two letters, one signed by AMA, AOA, AAFP and AAP presidents; second by ACP leaders, on nurses’ scope of practice:

http://www.nejm.org/doi/full/10.1056/NEJMc1013895

 

[MJB]

All I have to know is that I know a woman who did not even have a BSN when I started Med School....and by the time I'm 6 months into internship next year, she will be a Nurse Practitioner, a full 2.5 years before I can practice medicine independently like they want to.

 

[notinkansas]

Makes me wonder where it stops. What will distinguish doctors from nurses? Or will we be able to just do away with medical school and residency eventually?

 

[JustPlainBill]

Makes me wonder where it stops. What will distinguish doctors from nurses? Or will we be able to just do away with medical school and residency eventually?

Had a really interesting experience this morning --- a relative had been taken to the ED for palpitations and was placed in 23 hour obs...no biggie, been on the physician end of this more than once but now I get to sit in the guest chair and watch as things unfold. ED doc was thorough and very good although he left a little out in asking pertinent history questions but nothing I could fault him for on standard of care....

This AM, I happened to be in the room when the ANP that worked for the cardiologist on call happened to waltz into the room....I was able to keep my mouth shut for a while but I have never witnessed such a poor, disorganized way of taking a history than I saw this AM. Rather than develop the HPI with an OLDCARTS type method, I could almost see her running down the list of differentials with one specific question per differential....and nothing else regarding that differential. If the patient didn't affirm the one question the NP asked, that was crossed off the DDX list.....as opposed to eliciting information from the patient and letting them describe what brought them into the hospital and then working up the DDX based on the whole picture.....

The cardiologist came in later and used the information from the NP and was about to start making some decisions when I couldn't take it anymore and asked the patient a few leading questions which caused them to say things that were factual, germaine, and had not been elicited previously but changed the treatment plan. I didn't know how to play it and didn't want to interfere but it was rather appalling at what was missed and not elicited.....

I shudder to think how this would have went down if the NP had independent practice rights.....

 

[Charles_Carmichael]

I shudder to think how this would have went down if the NP had independent practice rights.....

Unfortunately, they already have independence in several states. It's a matter of damage control now, not prevention, IMO.

From my limited understanding of medicine, it's hard to imagine that those with lesser training than physicians, on average, can come up with the same extensive Ddx as physicians can. Like Taurus mentions, it'll ultimately get down to malpractice lawsuits that will limit NP/DNP independent practice...unfortunately for patients. At least, that's my opinion.