Doctor shortage: A nurse may soon be your doctor

[RogueUnicorn]

i don't know how it works in other states, but from what i've seen, the md-np cooperation/supervision is mostly behind the scenes. it's not like the np sees a patient and goes 'ok now the doc will see you.' the np is given a degree of autonomy to function. the supervising physician and the np review cases monthly (depends on the arrangement, of course) and discuss outcomes, treatment strategies, etc to get on the same page

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[IndianVercetti]

This is one issue I'm a bit uninformed on: if a Physician-DNP clinic is in practice, and the DNP makes an error and the patient files a lawsuit, would this lawsuit ultimately still be targeted at the physician since he was overseeing the DNP? or would the lawsuit still be targeted solely at the DNP?

 

[RogueUnicorn]

pretty sure the doc is on hook

edit: also, in a lawsuit you can name whoever you want as a defendant. whether it sticks or not is for the lawyers to figure out, i'm sure

 

[IndianVercetti]

mooshika, I'm very interested to hear your perspective on this malpractice issue.

if you feel that DNPs deserve the autonomy of PCPs, don't you feel they should also obtain malpractice insurance, and take on responsibility for their authority?

 

[Instatewaiter]

chiropracters (sic) claim to practice medicine. They even put it on the neon signs outside their offices. But really, who cares what they call themselves? They didn't need any help from the medical community to ruin their reputation, they did it themselves as will DNP's if that is actually the case.

Yeah... no they dont. That would be practicing medicine without a license and is illegal.

Their signs say Chiropractor.

The other point I want to make is that you will not really know how much of your education you will be calling on for your daily medical practice until you have been practicing for a period of time.

Oh you mean like the 2 years you spend in the hospital while in medical school? Those don't give you any idea how much of your education you are going to be calling on? Seriously, just stop talking. You are clearly talking out of your ass.

 

[IndianVercetti]

also, mooshika, is your name supposed to reference ganapati/ganesh by any chance?

 

[Perrotfish]

That is why a combined physician/NP model makes sense. Where a physician is available to treat the other 20%. Independent practice removes the physician oversight to catch that 20% that need more advanced care. I don't think there are too many people on here arguing that DNPs shouldn't exist. Rather they are arguing that independent practice rights are dangerous

This makes less sense than you think it does. The patients don't come labeled as 'easy', 'moderate', and 'difficult' like practice MCAT questions, figuring out which ones are in the difficult 20% is the hardest part of the physicians' job. The reason physicians get so much training is that they need to be able to recognize when someone is showing early warning signs of a very serious illness based on symptoms that are only slightly different from the common cold.

I can understand NPs that argue that they are also adequatly trained to do this and should be allowed to practice independently, and I can understand the argument that nurses should stick with being nurses. However the argument that NPs are reasonable primary care practicioners as long as someone is supervising them is *****ic. There's no way for them to know which patients are beyond their level of training because those patients are the ones they don't recognize in time. Actually this is a major argument that NPs use to defend their right to independent practice: because it is virtually impossible for a physician to supervise NPs in any meaningful way most of their work is basically independent practice right now. I know it would gall me to give part of my earnings to someone who did nothing other than blindly sign off on all of my work.

 

[dru2002]

This makes less sense than you think it does. The patients don't come labeled as 'easy', 'moderate', and 'difficult' like practice MCAT questions, figuring out which ones are in the difficult 20% is the hardest part of the physicians' job. The reason physicians get so much training is that they need to be able to recognize when someone is showing early warning signs of a very serious illness based on symptoms that are only slightly different from the common cold.

I can understand NPs that argue that they are also adequatly trained to do this and should be allowed to practice independently, and I can understand the argument that nurses should stick with being nurses. However the argument that NPs are reasonable primary care practicioners as long as someone is supervising them is *****ic. There's no way for them to know which patients are beyond their level of training because those patients are the ones they don't recognize in time. Actually this is a major argument that NPs use to defend their right to independent practice: because it is virtually impossible for a physician to supervise NPs in any meaningful way most of their work is basically independent practice right now. I know it would gall me to give part of my earnings to someone who did nothing other than blindly sign off on all of my work.

I don't know we had a very healthy population of marines but the Independent Duty Corpsman was still routinely evaluated by the physician. Through chart reviews and occasionally sitting in while a patient was seen. On more than one occasion treatment plans and diagnoses were changed. I will concede that IDCs have less training than DNPs so it isn't a perfect example but nonetheless the point stands. I know doctors are busy but one doing his job should be doing more than just signing off on charts blindly.

 

[Perrotfish]

I don't know we had a very healthy population of marines but the Independent Duty Corpsman was still routinely evaluated by the physician. Through chart reviews and occasionally sitting in while a patient was seen. On more than one occasion treatment plans and diagnoses were changed. I will concede that IDCs have less training than DNPs so it isn't a perfect example but nonetheless the point stands. I know doctors are busy but one doing his job should be doing more than just signing off on charts blindly.

The problem is that, even if the doctor is reviewing every single chart, he is assuming that the noted symptoms were all the symptoms that the patient actually had. The doc can very easily change the treatment for a given diagnosis, but he can't change the diagnosis itself unless there was a competent exam earlier on. If a practicioner isn't competent to make the diagnosis, they're not competent to do the exam in the first place.

Restricting your practice to acive duty serice personel is probably the exception to the rule, of course. The sheer number of medical screening tests they get, combined with the fact that they are physically fit and exactly the wrong age to come down with anything serious, is probably enough to keep anything too terrible from getting overlooked.

 

[Instatewaiter]

This makes less sense than you think it does. The patients don't come labeled as 'easy', 'moderate', and 'difficult' like practice MCAT questions, figuring out which ones are in the difficult 20% is the hardest part of the physicians' job. The reason physicians get so much training is that they need to be able to recognize when someone is showing early warning signs of a very serious illness based on symptoms that are only slightly different from the common cold.

A good point on many levels.


Here's an example of how, without proper training something seems simple but isnt:

A 50 year old man comes into your office for a normal check up. He's happy that finally has started to lose the weight he's been trying to for so long. His wife's happy too Things are going well but his age is catching up to him because he's more tired after work. Physical exam is basically normal except for some slight yellowing of the eyes and maybe the head. He has good range of motion in his joints, good strength and no back pain what so ever. His lungs sound great and his heart is normal. Prostate feels fine although a bit enlarged. Abdomen is soft and not tender when you mash on it. There are no masses felt and his bowels sound normal when you listen.

So basically a normal guy except that he has pancreatic cancer... which if you didnt order the immediate workup for this guy, would invariably kill him.

This guy sounds like the "easy" patient but is not.

 

[RogueUnicorn]

to be fair it probably will kill him regardless, right?

 

[Ischemic]

Hi,
Moo character here. ...you are saying you hate me? No doubt you do. As far as hierarchy here, all I see are a bunch of made-up names with avatars. Who is an attending and who is a nurse? Is that really an issue here... you just don't like me.

Hey moo, just like in every other one of your posts you are very quick to jump to conclusions without at least thinking a little bit before you post. I said your blatant disrespectful and arrogant attitude reminded me of someone else and then said everyone hated that person. No where in that statement did I say I hated YOU but I did imply that if you keep this up people will generally dislike you. You further demonstrated your lack of reading comprehension by quickly jumping to how SDN is full of just indistinguishable avatars and their anonymous authors from my comment on how you should recognize how hierarchical medicine is. No where did I say you had to respect people on SDN, but that you should respect your superiors WHEN YOU'RE ACTUALLY IN THE HOSPITAL AS A MEDICAL STUDENT/RESIDENT. (Note that I all capsed this so that you pay attention to it).

Your penchant for rash postings and quickly jumping to conclusions makes me wonder about your capabilities as a nurse and future physician. Will you just automatically diagnose someone as having a bad migraine and send him home with some tylenol just to find out he actually had an intracranial hemorrhage? Hmmm maybe you should stick with nursing after all so that someone can supervise your work...

 

[Ischemic]

A good point on many levels.


Here's an example of how, without proper training something seems simple but isnt:

A 50 year old man comes into your office for a normal check up. He's happy that finally has started to lose the weight he's been trying to for so long. His wife's happy too Things are going well but his age is catching up to him because he's more tired after work. Physical exam is basically normal except for some slight yellowing of the eyes and maybe the head. He has good range of motion in his joints, good strength and no back pain what so ever. His lungs sound great and his heart is normal. Prostate feels fine although a bit enlarged. Abdomen is soft and not tender when you mash on it. There are no masses felt and his bowels sound normal when you listen.

So basically a normal guy except that he has pancreatic cancer... which if you didnt order the immediate workup for this guy, would invariably kill him.

This guy sounds like the "easy" patient but is not.

So, I'm assuming that the key feature here is the yellowing of the eye. How would you rule out some type of liver disease as the cause of his jaundice? Because there was no pain in his URQ? Or would you do the workup because you wanted to see why he had scleral icterus.

 

[surftheiop]

A good point on many levels.


Here's an example of how, without proper training something seems simple but isnt:

A 50 year old man comes into your office for a normal check up. He's happy that finally has started to lose the weight he's been trying to for so long. His wife's happy too Things are going well but his age is catching up to him because he's more tired after work. Physical exam is basically normal except for some slight yellowing of the eyes and maybe the head. He has good range of motion in his joints, good strength and no back pain what so ever. His lungs sound great and his heart is normal. Prostate feels fine although a bit enlarged. Abdomen is soft and not tender when you mash on it. There are no masses felt and his bowels sound normal when you listen.

So basically a normal guy except that he has pancreatic cancer... which if you didnt order the immediate workup for this guy, would invariably kill him.

This guy sounds like the "easy" patient but is not.

Sounds like we should just full body image everything that comes through the door, because if it saves even one person its worth it right?

 

[mcgyver]

Sounds like we should just full body image everything that comes through the door, because if it saves even one person its worth it right?

dude it's far from checking everybody that comes through the door. yellowing of the eyes (painless jaundice) and unexpected weight loss = check for pancreatic cancer. i'm MS1 and even I know that.

 

[45408]

Fixed that for you

Physicians do use a lot of chemistry though. The details of an SN2 reaction aren't relevant, but knowing which drugs buffer what ions is actually pretty important. We spent a while on rounds today talking about acidosis, anion gaps, acid excretion, etc. Suffice it to say, an extensive background in science is more useful than it might seem to a pre-med.

 

[45408]

Sounds like we should just full body image everything that comes through the door, because if it saves even one person its worth it right?

No, because after doing 1000 scans, you'd cause cancer in one of those patients.

You don't image everyone, but you should know who/when to image based on subtle findings in the history and physical.

 

[The right Path]

mooshika, I'm very interested to hear your perspective on this malpractice issue.

if you feel that DNPs deserve the autonomy of PCPs, don't you feel they should also obtain malpractice insurance, and take on responsibility for their authority?

I know this was addressed to Mooshika, but I thought I'd fill you guys in on the malpractice insurance issue. Registered Nurses (even the lowliest SNF bedside nurse) have malpractice insurance. Either through their employer, or individually purchased. Many have both as there is sometimes a conflict of interest between facility and RN. An advanced practice RN such as an NP or CRNA would most certainly carry employer based and/or personal malpractice insurance, and may very well be required as a condition of licensure by the state.

I don't know we had a very healthy population of marines but the Independent Duty Corpsman was still routinely evaluated by the physician. Through chart reviews and occasionally sitting in while a patient was seen. On more than one occasion treatment plans and diagnoses were changed. I will concede that IDCs have less training than DNPs so it isn't a perfect example but nonetheless the point stands. I know doctors are busy but one doing his job should be doing more than just signing off on charts blindly.

I just wanted to point out that you'd see changes in diagnosis and treatment plans with physicians reviewing other physician's cases. I'm not advocating for more or less physician oversight of midlevel practitioners, by the way- I'm just pointing out the fact that opinions on management will differ between those of the same training. As I have stated before (not in this thread)- I believe the bottom line in evaluating the efficacy and safety and cost effectiveness of midlevels (independent or otherwise) is the outcomes... which apparently has not been satisfactorily assessed. This (in my opinion) trumps the complaints of disparity in salary, cost of education, turf and prestige guarding, title confusion, length of training, and to some degree, content of curricula. The proof is in the pudding, isn't it? This is America, and we want results, right? Or in this generation of reality show, drama loving antics can we not get past hysterical abortions of logic? Props in particular to Blue Dog, Kaushik, Hoody, Perrotfish and others that I can't recall names off the top of my head right now for maintaining civility and reason when addressing this issue.

A good point on many levels.


Here's an example of how, without proper training something seems simple but isnt:

A 50 year old man comes into your office for a normal check up. He's happy that finally has started to lose the weight he's been trying to for so long. His wife's happy too Things are going well but his age is catching up to him because he's more tired after work. Physical exam is basically normal except for some slight yellowing of the eyes and maybe the head. He has good range of motion in his joints, good strength and no back pain what so ever. His lungs sound great and his heart is normal. Prostate feels fine although a bit enlarged. Abdomen is soft and not tender when you mash on it. There are no masses felt and his bowels sound normal when you listen.

So basically a normal guy except that he has pancreatic cancer... which if you didnt order the immediate workup for this guy, would invariably kill him.

This guy sounds like the "easy" patient but is not.

I get what you're saying, but I just want to advise you to pick a different example. I don't know of a bedside RN, let alone one that is trained in diagnosing medical conditions that would not recognize the red flags of rapid weight loss without radical change in diet and exercise or surgery, not to mention the jaundice and icteric sclerae, throw the fatigue in there, what the hell. As you seem to imply, yes, these are not particularly specific ROS findings. However, again, I don't know of a bedside RN, let alone an advanced practice RN that would not realize that a hepatic panel (ALT, AST, LDH, direct and indirect bili), hepatitis panel (r/o viral cause), and of course amylase and lipase. When the pt. comes back in for f/u with the lab results, which clearly indicate a pancreatic process, the next step would be abd. CT and after those results, appropriate referral for biopsy, and so on.

So my point being, I agree this is not an easy patient- in a sense of treatment and prognosis. However, this guy is easily worked up and properly referred.

 

[surftheiop]

No, because after doing 1000 scans, you'd cause cancer in one of those patients.

You don't image everyone, but you should know who/when to image based on subtle findings in the history and physical.

I wasn't actually claiming that we should do that, I was alluding to the fact its pointless to make up some hypothetical and claim that is a good reason why providers need a certain level of education without considering the cost to society of educating everyone to that level.

I'm sure we could just as easily make up stories as to why all FP docs should also be required to complete a residency in psychiatry.

My point is that no matter the amount of education someone has, there will be cases when they "miss the ball". But you need some statistics to be able to weigh the times when a provider screws up with the total societal cost of education.

Like I said, if our number one goals was to be sure no zebras slipped through, maybe all FP should complete Derm and Cardiology residencies as well to make sure they don't miss any odd presentations of skin cancers or heart problems.

 

[surftheiop]

dude it's far from checking everybody that comes through the door. yellowing of the eyes (painless jaundice) and unexpected weight loss = check for pancreatic cancer. i'm MS1 and even I know that.

Ok, so you learned that in a few months of medical education.... how is that supporting the guy who posting a claim that this is the reason it takes 8 years of training to be a good FP?

You just proved my point to an extent

 

[Perrotfish]

Ok, so you learned that in a few months of medical education.... how is that supporting the guy who posting a claim that this is the reason it takes 8 years of training to be a good FP?

You just proved my point to an extent

I actually started writing up an example in my origional post, but didn't for exactly this reason: I knew that whatever nurse was reading would say 'but anyone could have figured that out'. And they'd be right, since as a second year medical student I still don't have much more training than a DNP.

Anyway, since it's too late now, here is one example I've seen:

A long time HMO patient (I'm going to guess that means NPs) comes in asking for treatment for an acute attack of gout. The guy stated that he had previously been treated acutely for gout, which ran in his family, which had ultimately resolved 'after a while' but now wanted not just to be treated for the current attack but also to be given something to prevent recurences. His arms were covered in red plaques with silver scales, and his blood chemistry showed normal levels of uric acid. Long story short the guy had been suffering from psoriatic arthritis for years and his NP had never actualy bothered to confirm their diagnosis in any way: they were apparently unaware that psoriatic arthritis and pseudogout both had the same presentation as gout so when they saw gout like symptoms they treated emperically rather than running any tests. Obscure cause of a common presentation + subpar training = years of human misery.

Again, the point here is not that NPs couldn't possibly be qualified to do this job. The point is that I don't so how they could be qualified to do it under the supervision of a physician but not on their own. Unless supervision means the physician is physicially standing in the room watching them examine and diagnose each patient it seems like they either need to be considered competent to practice on their own or not considered competent to practice at all.

 

[45408]

Ok, so you learned that in a few months of medical education.... how is that supporting the guy who posting a claim that this is the reason it takes 8 years of training to be a good FP?

You just proved my point to an extent

Because there's another 300 scenarios that he hasn't learned yet.

 

[The right Path]

dude it's far from checking everybody that comes through the door. yellowing of the eyes (painless jaundice) and unexpected weight loss = check for pancreatic cancer. i'm MS1 and even I know that.

Your first suspicion would be infectious hepatitis, not pancreatic cancer. The point (I think) that Instate Waiter was trying to get across is that an inadequately trained practitioner would automatically make this assumption and treat for such without doing the proper work up to arrive at the correct diagnosis.

Such an egregious error is one more likely to be made by a lazy or overtired, overhurried physician or practitioner- in my opinion- since even entry level nursing would be sufficient to recognize that the above mentioned symptoms are not specific to infectious hepatitis. As you pointed out yourself, you realize that with only one year of medical education.

 

[45408]

I get what you're saying, but I just want to advise you to pick a different example. I don't know of a bedside RN, let alone one that is trained in diagnosing medical conditions that would not recognize the red flags of rapid weight loss without radical change in diet and exercise or surgery, not to mention the jaundice and icteric sclerae, throw the fatigue in there, what the hell. As you seem to imply, yes, these are not particularly specific ROS findings. However, again, I don't know of a bedside RN, let alone an advanced practice RN that would not realize that a hepatic panel (ALT, AST, LDH, direct and indirect bili), hepatitis panel (r/o viral cause), and of course amylase and lipase. When the pt. comes back in for f/u with the lab results, which clearly indicate a pancreatic process, the next step would be abd. CT and after those results, appropriate referral for biopsy, and so on.

I do.

 

[AbbyNormal]

Unless supervision means the physician is physicially standing in the room watching them examine and diagnose each patient it seems like they either need to be considered competent to practice on their own or not considered competent to practice at all.

Is that really what you think mid-level nurses supervised by physicians are like? Or are you being sarcastic? I can't tell.

 

[The right Path]

I actually started writing up an example in my origional post, but didn't for exactly this reason: I knew that whatever nurse was reading would say 'but anyone could have figured that out'.]

Lolz, I did just that

And they'd be right, since as a second year medical student I still don't have much more training than a DNP.

Anyway, since it's too late now, here is one example I've seen:

A long time HMO patient (I'm going to guess that means NPs) comes in asking for treatment for an acute attack of gout. The guy stated that he had previously been treated acutely for gout, which ran in his family, which had ultimately resolved 'after a while' but now wanted not just to be treated for the current attack but also to be given something to prevent recurences. His arms were covered in red plaques with silver scales, and his blood chemistry showed normal levels of uric acid. Long story short the guy had been suffering from psoriatic arthritis for years and his NP had never actualy bothered to confirm their diagnosis in any way: they were apparently unaware that psoriatic arthritis and pseudogout both had the same presentation as gout so when they saw gout like symptoms they treated emperically rather than running any tests. Obscure cause of a common presentation + subpar training = years of human misery.

Inadequate work up leading to incorrect diagnosis and inapproriate (ineffective and/or harmful) treatment is the ambrosia of JCAHO and other regulatory agencies. And not a phenomenon singular to the practice of midlevels. Now, the million dollar question is...... Are these types of problems disproportionally occuring under the care of midlevels? What really are the contributing factors that lead to subpar care? The Joint Commission has built an empire just for this quest.

Again, the point here is not that NPs couldn't possibly be qualified to do this job. The point is that I don't so how they could be qualified to do it under the supervision of a physician but not on their own. Unless supervision means the physician is physicially standing in the room watching them examine and diagnose each patient it seems like they either need to be considered competent to practice on their own or not considered competent to practice at all.

That's a legitimate concern. How should "physician oversight" be defined and measured? What degree of physician oversight (if any) is needed to ensure safe, quality practice?

It is not a cause that is personally relevant to me, so I will not be taking it up- but I may keep half an eye on it from the sidelines

 

[The right Path]

I do.

Seriously? Do tell.

 

[deleted191570]

Your first suspicion would be infectious hepatitis, not pancreatic cancer. The point (I think) that Instate Waiter was trying to get across is that an inadequately trained practitioner would automatically make this assumption and treat for such without doing the proper work up to arrive at the correct diagnosis.

Such an egregious error is one more likely to be made by a lazy or overtired, overhurried physician or practitioner- in my opinion- since even entry level nursing would be sufficient to recognize that the above mentioned symptoms are not specific to infectious hepatitis. As you pointed out yourself, you realize that with only one year of medical education.

What worries me is, would you be qualified to treat for hepatitis if it was that? The literature on diseases like this are ever changing.

I'm not saying that an MD/DO would necessarily know either. But the future of medicine is that you MUST keep up with the lit to remain effective and know more about diseases than many of your patients...

 

[surftheiop]

Because there's another 300 scenarios that he hasn't learned yet.

I don't disagree with you all's conclusions necessarily, just when I see awful arguments I like to point them out

 

[deleted191570]

An advanced practice RN such as an NP or CRNA would most certainly carry employer based and/or personal malpractice insurance, and may very well be required as a condition of licensure by the state.



I just wanted to point out that you'd see changes in diagnosis and treatment plans with physicians reviewing other physician's cases. I'm not advocating for more or less physician oversight of midlevel practitioners, by the way- I'm just pointing out the fact that opinions on management will differ between those of the same training. As I have stated before (not in this thread)- I believe the bottom line in evaluating the efficacy and safety and cost effectiveness of midlevels (independent or otherwise) is the outcomes... which apparently has not been satisfactorily assessed. This (in my opinion) trumps the complaints of disparity in salary, cost of education, turf and prestige guarding, title confusion, length of training, and to some degree, content of curricula. The proof is in the pudding, isn't it? This is America, and we want results, right? Or in this generation of reality show, drama loving antics can we not get past hysterical abortions of logic?

I get what you're saying, but the issue is regulation, which is always necessary to prevent abuse (and to protect people from things like frivolous lawsuits). I might be able to mix and pour the best drinks on the planet, but to work at a bar in many states, if I don't have a bartending license, it wouldn't make a bit of difference. Licensing standards for the ability to practice medicine independently need to be equally applied to everyone.

Now if you say the licensing standards to practice independent primary care should be changed, then that's a different story... and needs to be examined. That's where all the patient outcome studies would help. But the way things are now, that's not the case. And you either need to argue for reform or abide by the system, not try to circumvent it.

 

[The right Path]

What worries me is, would you be qualified to treat for hepatitis if it was that? The literature on diseases like this are ever changing.

I'm not saying that an MD/DO would necessarily know either. But the future of medicine is that you MUST keep up with the lit to remain effective and know more about diseases than many of your patients...

Who me? No, I am not qualified to diagnose or decide treatment for medical conditions. I am not an advanced practice RN. Nor a physician. However, as a regular old scut-tastic RN, I am expected to recognize them to a considerable extent and also to be knowledgable about appropriate treatments, etc. I am also required to continually update my education relevant to my practice.

One would hope that an MD/DO would know how to treat hepatitis, since that is his/her job. One would also hope that a NP would be knowledgable in such as that is his/her job. Physicians and practitioners also are expected to keep abreast of current best practices and cutting edge breakthroughs.

 

[deleted191570]

Who me? No, I am not qualified to diagnose or decide treatment for medical conditions. I am not an advanced practice RN. Nor a physician. However, as a regular old scut-tastic RN, I am expected to recognize them to a considerable extent and also to be knowledgable about appropriate treatments, etc. I am also required to continually update my education relevant to my practice.

One would hope that an MD/DO would know how to treat hepatitis, since that is his/her job. One would also hope that a NP would be knowledgable in such as that is his/her job. Physicians and practitioners also are expected to keep abreast of current best practices and cutting edge breakthroughs.

Yeah, you'd hope so, but I unfortunately I doubt many PCPs would know the latest cutting edge treatment for something like HepB. I see this as a problem for primary care in general as its breadth is so great.

My personal concern is this: oftentimes I read/hear of people going the NP route because the MD/DO route is too long/arduous/requires too much sacrifice. I think a lot of med students get disheartened too, because they realize that the sacrifice + workload commitment never really gets better unless you go to a "lifestyle" specialty. So in the ever-expanding and ever-more-complicated world of primary care, are we really doing ourselves and society any favors by expanding the roles of PCPs even further?

 

[The right Path]

An advanced practice RN such as an NP or CRNA would most certainly carry employer based and/or personal malpractice insurance, and may very well be required as a condition of licensure by the state.



I just wanted to point out that you'd see changes in diagnosis and treatment plans with physicians reviewing other physician's cases. I'm not advocating for more or less physician oversight of midlevel practitioners, by the way- I'm just pointing out the fact that opinions on management will differ between those of the same training. As I have stated before (not in this thread)- I believe the bottom line in evaluating the efficacy and safety and cost effectiveness of midlevels (independent or otherwise) is the outcomes... which apparently has not been satisfactorily assessed. This (in my opinion) trumps the complaints of disparity in salary, cost of education, turf and prestige guarding, title confusion, length of training, and to some degree, content of curricula. The proof is in the pudding, isn't it? This is America, and we want results, right? Or in this generation of reality show, drama loving antics can we not get past hysterical abortions of logic? Props in particular to Blue Dog, Kaushik, Hoody, Perrotfish and others that I can't recall names off the top of my head right now for maintaining civility and reason when addressing this issue.

I get what you're saying, but the issue is regulation, which is always necessary to prevent abuse (and to protect people from things like frivolous lawsuits). I might be able to mix and pour the best drinks on the planet, but to work at a bar in many states, if I don't have a bartending license, it wouldn't make a bit of difference. Licensing standards for the ability to practice medicine independently need to be equally applied to everyone.

Now if you say the licensing standards to practice independent primary care should be changed, then that's a different story... and needs to be examined. That's where all the patient outcome studies would help. But the way things are now, that's not the case. And you either need to argue for reform or abide by the system, not try to circumvent it.

Do you get what I'm saying? Let me break it down for you.

1. About malpractice. Some posters have complained that among the various injustices, that midlevels don't have to bear the responsibility of malpractice insurance. That is incorrect. Any idiot that doesn't carry insurance is putting themselves at risk for losing all their assests and finding themselves in financial ruin. This is true for a bedside RN and even more true for a NP or CRNA. In fact, due to the increased liability, malpractice insurance may be required for licensure for an advanced practice RN. I say "may" because truly, I don't know for sure. It might differ state by state, and franky, I don't care enough to google. Next time I see an NP or CRNA and I think to ask, I'll ask.

2. I believe I made my position clear regarding my opinion of midlevel practice (see bolded phrase in my post). I'm not trying to argue for reform, abide by the system, or circumvent it. I am saying that I'm not interested in hearing arguments that follow along the lines of "dey took er jerbs!" As far as public safety and interest go, what matters are proven results. Outcomes. That is what I base my opinion (on this subject) on, and what I expect that regulating bodies should determine licensing standards on. I hope that clarifies things.

3. I suppose I should also for the record state that I do not have any advance practice aspirations, nor primary care interests..... so really this issue is of marginal personal interest to me.

 

[deleted191570]

Do you get what I'm saying? Let me break it down for you.

1. About malpractice. Some posters have complained that among the various injustices, that midlevels don't have to bear the responsibility of malpractice insurance. That is incorrect. Any idiot that doesn't carry insurance is putting themselves at risk for losing all their assests and finding themselves in financial ruin. This is true for a bedside RN and even more true for a NP or CRNA. In fact, due to the increased liability, malpractice insurance may be required for licensure for an advanced practice RN. I say "may" because truly, I don't know for sure. It might differ state by state, and franky, I don't care enough to google. Next time I see an NP or CRNA and I think to ask, I'll ask.

2. I believe I made my position clear regarding my opinion of midlevel practice (see bolded phrase in my post). I'm not trying to argue for reform, abide by the system, or circumvent it. I am saying that I'm not interested in hearing arguments that follow along the lines of "dey took er jerbs!" As far as public safety and interest go, what matters are proven results. Outcomes. That is what I base my opinion (on this subject) on, and what I expect that regulating bodies should determine licensing standards on. I hope that clarifies things.

3. I suppose I should also for the record state that I do not have any advance practice aspirations, nor primary care interests..... so really this issue is of marginal personal interest to me.

Hm. I did get what you were saying.

1. Okay. I haven't mentioned insurance at all, and most likely agree with you. I'm pretty certain that insurance companies are gonna figure this one out for themselves anyway, so I don't even think it's worth much consideration. Just didn't think that was the most important point to be made.

2. Okay. I was making an argument of my own for the sake of discussion, but I guess you're not interested in what I had to say.

3. Okay. #2 makes sense then.

 

[The right Path]

Yeah, you'd hope so, but I unfortunately I doubt many PCPs would know the latest cutting edge treatment for something like HepB. I see this as a problem for primary care in general as its breadth is so great.

My personal concern is this: oftentimes I read/hear of people going the NP route because the MD/DO route is too long/arduous/requires too much sacrifice. I think a lot of med students get disheartened too, because they realize that the sacrifice + workload commitment never really gets better unless you go to a "lifestyle" specialty. So in the ever-expanding and ever-more-complicated world of primary care, are we really doing ourselves and society any favors by expanding the roles of PCPs even further?

The increasing complexity of comorbid management, etc, is why there are so many specialties and subspecialties. That does not eliminate the role of the primary care provider who is absolutely needed for health care maintenance, illnesses, the surveillance of health problems that go beyond their scope, and the appropriate referral and coordination of more specialized care.

If midlevels can safely and comparably assist in this role, great. If not, then they shouldn't.

Is it a problem that primary care physicians incur so much debt and are compensated so poorly? Of course it is. That is a separate issue. For another time at this point because it's getting really late and I need to finish making dinner.

 

[deleted191570]

The increasing complexity of comorbid management, etc, is why there are so many specialties and subspecialties. That does not eliminate the role of the primary care provider who is absolutely needed for health care maintenance, illnesses, the surveillance of health problems that go beyond their scope, and the appropriate referral and coordination of more specialized care.

If midlevels can safely and comparably assist in this role, great. If not, then they shouldn't.

Is it a problem that primary care physicians incur so much debt and are compensated so poorly? Of course it is. That is a separate issue. For another time at this point because it's getting really late and I need to finish making dinner.

In the circular way these things tend to go, yes, I completely agree. Just wondering how to properly assess the capabilities of all involved, about which I have a current opinion.

Hope you enjoy your dinner.

Unrelated: I've been watching the Caps-Canadiens game on TV this whole time and have been wildly fluctuating between excitement and agitation-- haha.

 

[mooshika]

That is why a combined physician/NP model makes sense. Where a physician is available to treat the other 20%. Independent practice removes the physician oversight to catch that 20% that need more advanced care. I don't think there are too many people on here arguing that DNPs shouldn't exist. Rather they are arguing that independent practice rights are dangerous.

Also you addressed earlier the doctor that only uses 10% of what he has learned. No one knows going in what 10% they will need to know. If we could boil it down to that we could produce providers in a like a year. And of course he bashed the MCAT everyone hates it but the classes he took in order to do well on the MCAT more then likely have shaped the way he thinks and influences the decisions he makes as a doctor.

I agree, except about what you say about "oversight" because an NP can refer out and/or consult with the team and does not need someone to tell them they are looking at a problem that is out of their scope of practice. Even I can identify abnormal findings on most standard diagnostic tests and take the appropriate steps and interventions that are within my current scope of practice. What is more important than having some poor physician checking up on the NP's is establishing clear, reasonable, scope of practice guidelines for licensing. Professional providers can handle that just fine.

And my friend was right in a sense except that, as you say, since everything you learn builds on previous knowledge, it is hard to measure, as I said in the post. The education shapes your thinking. Then you learn to apply it when you are a resident or get with patients.

 

[mooshika]

If you (the NP) sign the orders your license is on the line. If someone provides treatment that is beyond their scope of practice, they can be held liable for that, just like an MD. NP's do not have to "run each case" by a doctor, the same way a PA does not have to. It is almost exactly the same.

Everybody has a "scope of practice" and that is why, for example, a Family Practice doc should be referring out patients who need psychiatric meds to a psychiatrist and preferably not handling it on their own.

And yes, of course advance practice nurses keep up with literature and research. Sometimes the words are really big and hard to understand though, for a lot of nurses, due to their sub-par education at the bowling alley.

pretty sure the doc is on hook

edit: also, in a lawsuit you can name whoever you want as a defendant. whether it sticks or not is for the lawyers to figure out, i'm sure

 

[235788]

Maybe there should be more nurse practitioners in places such as the ER. There would be far less drug seekers because the best they will all get is motrin and the deathly ill may get vic's X)

 

[IndianVercetti]

And yes, of course advance practice nurses keep up with literature and research. Sometimes the words are really big and hard to understand though, for a lot of nurses, due to their sub-par education at the bowling alley.

why do you feel the need to mock us when we are simply discussing the issues at hand? The reason people here are losing respect for you is because you are simply incapable of having an objective conversation without bringing your emotions into the conversation.

 

[mooshika]

I know this was addressed to Mooshika, but I thought I'd fill you guys in on the malpractice insurance issue. Registered Nurses (even the lowliest SNF bedside nurse) have malpractice insurance. Either through their employer, or individually purchased. Many have both as there is sometimes a conflict of interest between facility and RN. An advanced practice RN such as an NP or CRNA would most certainly carry employer based and/or personal malpractice insurance, and may very well be required as a condition of licensure by the state.



I just wanted to point out that you'd see changes in diagnosis and treatment plans with physicians reviewing other physician's cases. I'm not advocating for more or less physician oversight of midlevel practitioners, by the way- I'm just pointing out the fact that opinions on management will differ between those of the same training. As I have stated before (not in this thread)- I believe the bottom line in evaluating the efficacy and safety and cost effectiveness of midlevels (independent or otherwise) is the outcomes... which apparently has not been satisfactorily assessed. This (in my opinion) trumps the complaints of disparity in salary, cost of education, turf and prestige guarding, title confusion, length of training, and to some degree, content of curricula. The proof is in the pudding, isn't it? This is America, and we want results, right? Or in this generation of reality show, drama loving antics can we not get past hysterical abortions of logic? Props in particular to Blue Dog, Kaushik, Hoody, Perrotfish and others that I can't recall names off the top of my head right now for maintaining civility and reason when addressing this issue.



I get what you're saying, but I just want to advise you to pick a different example. I don't know of a bedside RN, let alone one that is trained in diagnosing medical conditions that would not recognize the red flags of rapid weight loss without radical change in diet and exercise or surgery, not to mention the jaundice and icteric sclerae, throw the fatigue in there, what the hell. As you seem to imply, yes, these are not particularly specific ROS findings. However, again, I don't know of a bedside RN, let alone an advanced practice RN that would not realize that a hepatic panel (ALT, AST, LDH, direct and indirect bili), hepatitis panel (r/o viral cause), and of course amylase and lipase. When the pt. comes back in for f/u with the lab results, which clearly indicate a pancreatic process, the next step would be abd. CT and after those results, appropriate referral for biopsy, and so on.

So my point being, I agree this is not an easy patient- in a sense of treatment and prognosis. However, this guy is easily worked up and properly referred.

This is a good example. An NP can have the first-line workup done, and order the appropriate labs/CT. Results would be interpreted by radiology and the NP would write referral/SOAP notes documenting findings and include a proposed diagnosis/course of treatment and send this guy on his merry way to a properly specialized physician (if he can get an appointment) I think a lot of people posting here, as I said before, really don't know what providers jobs are. I mean no disrespect at all, but once you see what and how healthcare teams work together, and what their specific knowledge bases are, you really have no basis upon which to form a conclusion about what scope of practice is and should be for any said professional.

 

[deleted191570]

I agree, except about what you say about "oversight" because an NP can refer out and/or consult with the team and does not need someone to tell them they are looking at a problem that is out of their scope of practice. Even I can identify abnormal findings on most standard diagnostic tests and take the appropriate steps and interventions that are within my current scope of practice. What is more important than having some poor physician checking up on the NP's is establishing clear, reasonable, scope of practice guidelines for licensing. Professional providers can handle that just fine.

How do you know what is and is not within your scope of practice? I am asking broadly here, for anyone that practices primary care: How do you know when you are outside your realm and should refer to a specialist?

(Before I get flamed, yes, I do have thoughts on this, but I am definitely looking for hear some good, thoughtful views in order to continue developing my own, since they are still pretty fluid.)

Everybody has a "scope of practice" and that is why, for example, a Family Practice doc should be referring out patients who need psychiatric meds to a psychiatrist and preferably not handling it on their own.

What constitutes a "psychiatric" med, and where should that line by drawn? ADHD? Mood disorder? Depressive disorder? Schizophrenia?

And yes, of course advance practice nurses keep up with literature and research. Sometimes the words are really big and hard to understand though, for a lot of nurses, due to their sub-par education at the bowling alley.

How do you know this? How many hours per week does an average APRN spend with literature? Is that comparable to the number of hours physicians spend?

 

[mooshika]

I am not sure why this matters to you, and no, I don't have time to thoroughly read every post and deeply consider it. You specifically wrote that I was just like someone that "everyone" hated, so I safely assumed that that included you, so thanks for that.

I am sorry you feel that I misunderstood your post. It was a little mean, and I'm not sure I deserve that. Here, I am less concerned about being popular on a message board than I probably should be, but I really appreciate your attempt to save my reputation among the avatars. I am just expressing my opinions. I am older and closer to death than you are. You would be cranky too.

love,
Moo

Hey moo, just like in every other one of your posts you are very quick to jump to conclusions without at least thinking a little bit before you post. I said your blatant disrespectful and arrogant attitude reminded me of someone else and then said everyone hated that person. No where in that statement did I say I hated YOU but I did imply that if you keep this up people will generally dislike you. You further demonstrated your lack of reading comprehension by quickly jumping to how SDN is full of just indistinguishable avatars and their anonymous authors from my comment on how you should recognize how hierarchical medicine is. No where did I say you had to respect people on SDN, but that you should respect your superiors WHEN YOU'RE ACTUALLY IN THE HOSPITAL AS A MEDICAL STUDENT/RESIDENT. (Note that I all capsed this so that you pay attention to it).

Your penchant for rash postings and quickly jumping to conclusions makes me wonder about your capabilities as a nurse and future physician. Will you just automatically diagnose someone as having a bad migraine and send him home with some tylenol just to find out he actually had an intracranial hemorrhage? Hmmm maybe you should stick with nursing after all so that someone can supervise your work...

 

[IndianVercetti]

I am not sure why this matters to you, and no, I don't have time to thoroughly read every post and deeply consider it. You specifically wrote that I was just like someone that "everyone" hated, so I safely assumed that that included you, so thanks for that.

I am sorry you feel that I misunderstood your post. It was a little mean, and I'm not sure I deserve that. Here, I am less concerned about being popular on a message board than I probably should be, but I really appreciate your attempt to save my reputation among the avatars. I am just expressing my opinions. I am older and closer to death than you are. You would be cranky too.

love,
Moo

mooshika, we're trying to have a well-developed discussion here. Whether or not you want to partake is your choice, but unless you can keep your emotions out of this, and try to objectively look at this issue from all three sides (physician, nurse, and patient), we'll get nowhere.

what is frustrating a lot of us, is that we have continued to state very pressing questions about this topic to you, and you seem to dismiss it as our "disrespect" for nursing.

Don't make this emotional, let's just discuss the issues - there are no winner and losers here.

edit: Also, how can you honestly state that all DNPs will continue to keep up on current literature and journal articles? Unlike MD/DOs there is no CME course credits required after graduation, which ensures that physicians are reading up on their material to stay current.

 

[mooshika]

...

 

[The right Path]

Hm. I did get what you were saying.

1. Okay. I haven't mentioned insurance at all, and most likely agree with you. I'm pretty certain that insurance companies are gonna figure this one out for themselves anyway, so I don't even think it's worth much consideration. Just didn't think that was the most important point to be made.

2. Okay. I was making an argument of my own for the sake of discussion, but I guess you're not interested in what I had to say.

3. Okay. #2 makes sense then.

I appologize for misunderstanding your intent to make an argument for the sake of discussion. I thought you were directing your post toward my personal interests and I thought I needed to explain that really my interest is only peripheral. I don't want to come across as not being interested in what you have to say.

I expanded on the malpractice insurance thing since it was included in the post you quoted.

In the circular way these things tend to go, yes, I completely agree. Just wondering how to properly assess the capabilities of all involved, about which I have a current opinion.

Hope you enjoy your dinner.

Unrelated: I've been watching the Caps-Canadiens game on TV this whole time and have been wildly fluctuating between excitement and agitation-- haha.

Bingo. That's what I think is a the heart of the matter. I like to hear well reasoned arguments and facts. That's about the limit of my involvement. I'd be more dedicated if I were envisioning a future in primary care (either as a physician or nurse). I don't see the issue as a threat to my future career (my inclination is toward forensic pathology), but a legitimate public health concern.

Lol- about going back and forth between SDN and the game. Good multitasking practice

 

[surftheiop]

mooshika, we're trying to have a well-developed discussion here. Whether or not you want to partake is your choice, but unless you can keep your emotions out of this, and try to objectively look at this issue from all three sides (physician, nurse, and patient), we'll get nowhere.

what is frustrating a lot of us, is that we have continued to state very pressing questions about this topic to you, and you seem to dismiss it as our "disrespect" for nursing.

Don't make this emotional, let's just discuss the issues - there are no winner and losers here.

edit: Also, how can you honestly state that all DNPs will continue to keep up on current literature and journal articles? Unlike MD/DOs there is no CME course credits required after graduation, which ensures that physicians are reading up on their material to stay current.

Projecting much?

 

[The right Path]

edit: Also, how can you honestly state that all DNPs will continue to keep up on current literature and journal articles? Unlike MD/DOs there is no CME course credits required after graduation, which ensures that physicians are reading up on their material to stay current.

The basic RN is required to acquire and keep track of continuing education units in order to maintain licensure. I think that the the number and other specifics vary from state to state, however. If there are additional untis required for advanced practice RNs, I do not know.

Also you'll find that CME/CEU requirements can be fulfilled by mindless jumping through hoops that don't really enhance knowledge or practice.

Truly staying current depends more on an individual's mindset than regulatory requirements.

 

[mooshika]

You are right, I have misinterpreted many questions as attacks on either my credibility, or my actual ability to read, so I apologize for that.

I have expressed some unpopular opinions and I have a dry sense of humor that can get misunderstood in writing, and it is not easy to distinguish between the nasty insults and earnest questions presented to me, so I really do offer my apologies for dismissing your efforts as incredible, and thank you for actually being respectful to me and asking me my opinion.

mooshika, we're trying to have a well-developed discussion here. Whether or not you want to partake is your choice, but unless you can keep your emotions out of this, and try to objectively look at this issue from all three sides (physician, nurse, and patient), we'll get nowhere.

what is frustrating a lot of us, is that we have continued to state very pressing questions about this topic to you, and you seem to dismiss it as our "disrespect" for nursing.

Don't make this emotional, let's just discuss the issues - there are no winner and losers here.

edit: Also, how can you honestly state that all DNPs will continue to keep up on current literature and journal articles? Unlike MD/DOs there is no CME course credits required after graduation, which ensures that physicians are reading up on their material to stay current.

 

[IndianVercetti]

You are right, I have misinterpreted many questions as attacks on either my credibility, or my actual ability to read, so I apologize for that.

I have expressed some unpopular opinions and I have a dry sense of humor that can get misunderstood in writing, and it is not easy to distinguish between the nasty insults and earnest questions presented to me, so I really do offer my apologies for dismissing your efforts as incredible, and thank you for actually being respectful to me and asking me my opinion.

I'm glad that we can reach peace in this discussion now. This was never a nurse vs. MD/DO discussion, but more a discussion of the growing roles of nurses in medical treatment.

As was mentioned a couple of posts up, nurses do have their own version of CME, and it will be interesting to see if and how these will be revised for the growing position of NPs. Without a doubt, NPs will play a prominent role in future healthcare, but these issues simply have to be ironed out.

I'm glad we're on the same page now.

Projecting much?

?