Family NP Student seeking Family MD Consultation

[StreetPharm]

Hey Everyone,
I just wanna start off saying that I have a huge respect for Family Medicine. I definitely can see the wide range of knowledge that is needed to adequately care for a scope in full lifespan of patients. I have so many questions and of course not to beat a dead horse but would like to ask MD opinions on the disparity of educational background in NPs and MDs.

I'll be honest. I never had the desire to become a physician and nursing has been a great fit for me. And it just so happens that we've gained the political power to see patients in the primary care setting without MD oversight in NYC. Being a student and understanding the educational background of physicians and the vast knowledge that is needed, I am scared of entering the workforce.

I absolutely love primary care. And I do not want to be a disservice to my patients, however I am also not in a position to go to medical school because of ... life. I want to be the best that I can and continue to rigorously learn the most that I can in attempts to fill the knowledge that is needed of physicians.

I understand no amount of reading can ever put me on par of an MD due to the apprenticeship that is gained from residency. So I am humbly asking for advice from Family Physicians on this forum for guidance as what I can do to become much more competent at my profession.

As of right now I have been interning at an internal medicine clinic and following the head MD. He has been teaching me how to start thinking medically and how to correctly approach patients with a set of symptomatology. I have also been heavily using Up to Date for standard of practice. I do have a biochemistry background so my physiology and pathophysiology understanding maybe a little better than the average nurse or np. I understand that standard of practice is just that and in order to really understand how to treat, I must know exactly how things work.

What would you say is a complex patient that you have seen stump NPs? Aside from knowledge do you think an NP can learn from experience and be able to provide equal care of an MD?

I've read so many things online and I've also seen with my own eyes. The only constant is that MD and NP knowledge is very disparate in the beginning. I've had an MD refer me to a surgeon for gallbladder polyps and luckily I took myself to GI first. I've also had NPs mismanage as well.

So I would just like to get some honest opinions on here and also guidance as to how I can be a better provider and learn to think through more complex patients. THank you all for your time.

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[deleted87716]

I have so many questions and of course not to beat a dead horse but would like to ask MD opinions on the disparity of educational background in NPs and MDs.

Here ya' go. Not an opinion, just facts: http://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf

 

[smq123]

I have worked with multiple NPs, and have been involved in the decision to hire or not hire NPs as well.

The main thing that I have found with NPs is, as you said, their quality varies widely. The issue is that their training paths are not consistent. MDs and DOs tend to go through pretty uniform curricula, so that the end product is often very similar. The ACGME helps guarantee that we all learn basically the same things. This is not true for NPs. Some NP schools are far better than others, some clinical rotations are far better than others, and some NPs are lucky enough to find good mentors when they get out of school, while others do not.

As a result, the quality of an NP (or a PA, for that matter) seems mostly driven by their personality and character. An MD/DO has 3 years of residency to learn how to think logically and evenly, to get their ego (somewhat) in check, to learn some self-confidence and leadership skills. An NP has to know this coming out of the gate, or the chances are high that they will never learn.

What would you say is a complex patient that you have seen stump NPs?

There is no good answer to this. I had an NP who was stumped by a patient who had chronic atrial fibrillation with a heart rate of 78. (Seriously; she was going to send the guy to the ER because the routine EKG said "ATRIAL FIBRILLATION" - I walked in to see him with her and he was sitting in the chair, reading a newspaper. Turned out that he had had a-fib for the previous 8 years and was already rate controlled.) I have also worked with an NP who was so comfortable managing tough patients that she would only call for help for the patient who developed diabetes in addition to his CHF, COPD, and was s/p liver transplant. Another NP could comfortably handle the paranoid schizophrenics who had terribly uncontrolled HTN, because "the CIA puts microphones in my blood pressure meds."

I have had NPs who couldn't explain the difference between Type 1 diabetes and Type 2 diabetes (and if your first thought was that one was insulin dependent and the other was not, then you have more reading to do on the subject). I worked with an NP who did not understand why you would need to check a Hepatitis C viral load if the patient had a positive Hep C antibody - "the antibody means that the patient has hepatitis C, right?" That same NP who had the patient with a-fib did not know how to calculate a CHADS-VASC Score, or what that even meant or why it was important. I worked with another NP who didn't know the difference between IgG and IgM. There's too much variability to answer this question coherently.

Aside from knowledge do you think an NP can learn from experience and be able to provide equal care of an MD?

No. I really don't think so.

Every NP that I have worked with who was truly good at their job all told me that they learned from their mentors. They did not rely on learning on experience; they all told me that they would not be as good as they are without strong physician mentors at their first jobs that held their hands, reviewed their charts, went over things in detail with them.

It's tough to learn good clinical medicine through experience alone, because there are a lot of things in medicine that we do that are counter intuitive. I worked with another NP who refused to do a pap on a pregnant woman because "you're not supposed to touch the cervix during pregnancy." And while I understand that (it makes intuitive sense), it's just flat out wrong.

I've had an MD refer me to a surgeon for gallbladder polyps and luckily I took myself to GI first. I've also had NPs mismanage as well.

I'm interested in why you say this. Why is referring to surgeon for gallbladder polyps incorrect? Why do you consider this to be mismanagement?

 

[deleted87716]

Why is referring to surgeon for gallbladder polyps incorrect? Why do you consider this to be mismanagement?

I wondered the same thing.

 

[StreetPharm]

Thanks for all the response guys. I definitely agree with the inconsistency in NP education. A lot of those things that you guys have mentioned I actually do know already as a student. But I guess like you said, it all depends on the educational background. I was hirely considering doing an NP residency program and I'm sure that will at least somewhat help my learning since they rotate you through each specialty and do a lot of education along with MD guidance.

As for the gallbladder issue. I'm just telling you guys because you asked so please don't take any offense to what I say or take anything the wrong way.

I'm a 33 y/o male with a hx of gout and hyperlipidemia. I went into the office because I would get these really sharp pains RUQ every once in a while when I took deep breaths. It would just happen randomly, not after food for any other reason besides deep breathing. It wouldn't last very long, maybe a minute and it'll subside. At the time I was an RN so I knew nothing and just though maybe I had some gallstones. My MD decided to send me for an RUQ US and found multiple polyps, none of them were measured btw. He referred me to surgery because of course these polyps are a risk factor for cancer. I didn't wanna get cut right away so I decided on a second opinion after reading from Up to Date about these polyps which are very commonly benign and if they aren't even over 1cm they just need to be monitored.

I went to GI and had them take a look at the US again and he suggested that those pains that are have may have been just gas. And that he wasn't concerned with the polyps and I should just repeat the US in 6 months to see if they have grown. I talked a couple MDs about it and they have also said the same thing to me.

How do you guys feel?



Back to the main topic. How come MDs have not combated the change in NP autonomy politically? It seems that being a midlevel serves it's purpose by needing to collaborate with an MD but also being able to offset some of the work. I'm young so I don't really know the history as to why NPs were allowed full autonomy if we all see that there is a huge disparity in knowledge?

 

[PlutoBoy]

I have worked with multiple NPs, and have been involved in the decision to hire or not hire NPs as well.

The main thing that I have found with NPs is, as you said, their quality varies widely. The issue is that their training paths are not consistent. MDs and DOs tend to go through pretty uniform curricula, so that the end product is often very similar. The ACGME helps guarantee that we all learn basically the same things. This is not true for NPs. Some NP schools are far better than others, some clinical rotations are far better than others, and some NPs are lucky enough to find good mentors when they get out of school, while others do not.

As a result, the quality of an NP (or a PA, for that matter) seems mostly driven by their personality and character. An MD/DO has 3 years of residency to learn how to think logically and evenly, to get their ego (somewhat) in check, to learn some self-confidence and leadership skills. An NP has to know this coming out of the gate, or the chances are high that they will never learn.



There is no good answer to this. I had an NP who was stumped by a patient who had chronic atrial fibrillation with a heart rate of 78. (Seriously; she was going to send the guy to the ER because the routine EKG said "ATRIAL FIBRILLATION" - I walked in to see him with her and he was sitting in the chair, reading a newspaper. Turned out that he had had a-fib for the previous 8 years and was already rate controlled.) I have also worked with an NP who was so comfortable managing tough patients that she would only call for help for the patient who developed diabetes in addition to his CHF, COPD, and was s/p liver transplant. Another NP could comfortably handle the paranoid schizophrenics who had terribly uncontrolled HTN, because "the CIA puts microphones in my blood pressure meds."

I have had NPs who couldn't explain the difference between Type 1 diabetes and Type 2 diabetes (and if your first thought was that one was insulin dependent and the other was not, then you have more reading to do on the subject). I worked with an NP who did not understand why you would need to check a Hepatitis C viral load if the patient had a positive Hep C antibody - "the antibody means that the patient has hepatitis C, right?" That same NP who had the patient with a-fib did not know how to calculate a CHADS-VASC Score, or what that even meant or why it was important. I worked with another NP who didn't know the difference between IgG and IgM. There's too much variability to answer this question coherently.



No. I really don't think so.

Every NP that I have worked with who was truly good at their job all told me that they learned from their mentors. They did not rely on learning on experience; they all told me that they would not be as good as they are without strong physician mentors at their first jobs that held their hands, reviewed their charts, went over things in detail with them.

It's tough to learn good clinical medicine through experience alone, because there are a lot of things in medicine that we do that are counter intuitive. I worked with another NP who refused to do a pap on a pregnant woman because "you're not supposed to touch the cervix during pregnancy." And while I understand that (it makes intuitive sense), it's just flat out wrong.



I'm interested in why you say this. Why is referring to surgeon for gallbladder polyps incorrect? Why do you consider this to be mismanagement?

At least your patient had afib. I worked with someone that sent a patient to the ER for a first degree AV block.

 

[deleted87716]

How come MDs have not combated the change in NP autonomy politically?

We have, and we continue to do so.

 

[StreetPharm]

Here ya' go. Not an opinion, just facts: http://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf

Yea I've read this article before.

 

[StreetPharm]

We have, and we continue to do so.

Have you guys gained any ground? I imagine it might be hard to roll back on things?

 

[smq123]

My MD decided to send me for an RUQ US and found multiple polyps, none of them were measured btw. He referred me to surgery because of course these polyps are a risk factor for cancer. I didn't wanna get cut right away so I decided on a second opinion after reading from Up to Date about these polyps which are very commonly benign and if they aren't even over 1cm they just need to be monitored.

I went to GI and had them take a look at the US again and he suggested that those pains that are have may have been just gas. And that he wasn't concerned with the polyps and I should just repeat the US in 6 months to see if they have grown. I talked a couple MDs about it and they have also said the same thing to me.

How do you guys feel?

Just because you are sent to a surgeon does not mean that you will necessarily be sent for surgery. The surgeon evaluates you to decide IF you need surgery. It is likely that he would have told you the same thing - repeat u/s in 6 months to see if they have grown. But, this way, if they have grown, then the surgeon already knows you, knows your history, and you don't have to wait to get in to see the surgeon. So I don't totally disagree with your reasoning, but I don't think that your PCP did anything wrong either.

 

[StreetPharm]

No. I really don't think so.

Every NP that I have worked with who was truly good at their job all told me that they learned from their mentors. They did not rely on learning on experience; they all told me that they would not be as good as they are without strong physician mentors at their first jobs that held their hands, reviewed their charts, went over things in detail with them.

It's tough to learn good clinical medicine through experience alone, because there are a lot of things in medicine that we do that are counter intuitive. I worked with another NP who refused to do a pap on a pregnant woman because "you're not supposed to touch the cervix during pregnancy." And while I understand that (it makes intuitive sense), it's just flat out wrong.

Ah yes that's is what I originally meant, experience in terms of practicing along with MD guidance.

After residency what do MDs do when they come across something they have not seen? Or if it is something they just can't figure out?

 

[StreetPharm]

Just because you are sent to a surgeon does not mean that you will necessarily be sent for surgery. The surgeon evaluates you to decide IF you need surgery. It is likely that he would have told you the same thing - repeat u/s in 6 months to see if they have grown. But, this way, if they have grown, then the surgeon already knows you, knows your history, and you don't have to wait to get in to see the surgeon. So I don't totally disagree with your reasoning, but I don't think that your PCP did anything wrong either.

You're right, I guess I did leave the part out where he called the surgeon in front of me and told me it definitely needed to come out and he didn't even see the US report yet. I guess as patient that just scared me right away.

 

[deleted87716]

Have you guys gained any ground? I imagine it might be hard to roll back on things?

We're not trying to roll anything back, just keeping things as they should be (e.g., physician-led patient care teams).

 

[PlutoBoy]

You're right, I guess I did leave the part out where he called the surgeon in front of me and told me it definitely needed to come out and he didn't even see the US report yet. I guess as patient that just scared me right away.

There are different ways to skin a cat. Your primary care doctor ordered the ultrasound because he suspected gallbladder disease. The US confirmed his suspicion. I guess your primary care doctor could argue that you have symptomatic polyps. In that case, cholecystectomy is appropriate.

If the GI thinks that the findings are incidental, then monitoring is appropriate, particularly if the polyp is small and you told him that you don't really want surgery.

I don't know that either of them are wrong without having more information.

 

[septoplasty]

Ah yes that's is what I originally meant, experience in terms of practicing along with MD guidance.

After residency what do MDs do when they come across something they have not seen? Or if it is something they just can't figure out?

The most logical thing, depending on the scenario is to seek more information, weather that's a more thorough H&P, redeveloping/investigating the DDx or curb siding a colleague to bounce ideas from. If this provokes something that isn't a part of your training realm, than referral is made.

Really, no "protocol" to this, just not doing the same thing over and over and expecting a different result.

 

[StreetPharm]

The most logical thing, depending on the scenario is to seek more information, weather that's a more thorough H&P, redeveloping/investigating the DDx or curb siding a colleague to bounce ideas from. If this provokes something that isn't a part of your training realm, than referral is made.

Really, no "protocol" to this, just not doing the same thing over and over and expecting a different result.

Are there any drawbacks to referring? I know many MDs say that some NPs will just toss referrals left and right, especially for new NPs. Is it because it causes a delay in care if it's something that can really be handled by any primary MD without referral?

 

[PlutoBoy]

Are there any drawbacks to referring? I know many MDs say that some NPs will just toss referrals left and right, especially for new NPs. Is it because it causes a delay in care if it's something that can really be handled by any primary MD without referral?

Unnecessary referrals (which is subjective to a certain extent) are wasteful and expensive.

Having said that, there are no to limited drawbacks for the referring physician.

 

[smq123]

Are there any drawbacks to referring? I know many MDs say that some NPs will just toss referrals left and right, especially for new NPs. Is it because it causes a delay in care if it's something that can really be handled by any primary MD without referral?

Unnecessary referrals (which is subjective to a certain extent) are wasteful and expensive.

Having said that, there are no to limited drawbacks for the referring physician.

Sort of. It used to be that there was no drawback at all for the referring physician.

It's still true that there is no legal drawback for the referring physician. But insurance companies are becoming increasingly less tolerant of unnecessary referrals, particularly with Medicaid patients. I would not be surprised if CMS started penalizing practices for "unnecessary" referrals within the next 15 years.

At my last job, we were given a list of the "most expensive" providers (and yes, the top of the list tended to be NPs); we then had to write a letter justifying why they were so expensive.

 

[septoplasty]

Are there any drawbacks to referring? I know many MDs say that some NPs will just toss referrals left and right, especially for new NPs. Is it because it causes a delay in care if it's something that can really be handled by any primary MD without referral?

There are, plutoboy and smq pointed out some of the key reasons why over referral is wrong on so many different levels, and sometimes a disservice to the patient.

The other angle I was also "taught" to look at was when I make a referral to a sub specialty provider, that might lead to unnecessary testing & therapeutics for the patient. Which in itself opens a huge pandoras box called "over diagnosis & treatment".

As for why MD's "say" NP's toss referrals, its based on anecdotal reasons. If the NP doesn't feel comfortable with something, they'll refer. Despite it being a routine question/management/procedure for an MD. I'm not sure if there is a study that shows referral occurrences in mid-levels vs. MD's.

Ex. Aspiration and Injection of a Knee Joint. We see TONS of referrals from mid-levels for this (granted, this keeps our doors open), me based on my FM training, can easily do these straight out of residency. So for the patient to get referred to a specialist (Ortho/SM), this only increases the cost for the patient, the system, prolongs wait times for other patients who have other things that the primary care provider is unable to manage all while really not providing any more "value" (yea, I bashed my CAQ, but in that case above, its what it is).

Totally a lot more than just hitting that refer to "Derm" or "Ob/Gyn" button.

 

[betamale]

ideally, 1 year internship/residency where you rotate through all the primary specialties such as inpatient medicine/peds, ER/urgent care, OB/GYN clinic + L&D, outpt FM clinic, outpt/inpt psych, outpt ortho, nursing home/geriatrics, and 2 wk electives in optho/ENT/pulm/cards/neuro/nephro/pain mgmt/gen surg

i do believe that the only way to become an awesome clinician is by time and experience, this goes for NP/PA/MD/DO.

Recommend Current Family Medicine or Current Medicine for textbook