Flying scalpels and the future of health care

[ProfMD]

Do you have any evidence that you can do a better job than a college student? Why shouldn't we just replace all pretend surgeons with college grads? You have no evidence or data to prove that you can do a better job than anyone else. I'm sure we can get rid of you and replace you with someone who is just as good but cheaper since you have no evidence saying otherwise.

Hyperbole is of little value in a debate. College students doing surgery is a far cry from APNs doing primary care in an area where no physician is or wants to practice (more below).

However, if a college grad can convince the medical board to given him a license, a hospital to give him privileges, patients willing to go to him for surgery, and is willing to take on the liability - sure lets see how that works for said college student.

That being said, I have only argued for APNs to be allowed independent practice in underserved areas after a several year period of training under a physician. Yes, there are arguments against this contention that you can look up in other threads. Otherwise, I think APNs are of great help doing things in a practice that do not require a physician. In this latter case, the APN is supervised.

Again, my point is, if you want to make an argument, then make an argument. All too often I see on this board arguments that are assumptions, personal attacks, snide comments, or just false.

And I see you still insist that I am a "pretend surgeon." Since I am not going to share my personal details on a public board and the "verified physician" request link is down at the moment, I guess I will just have to accept your disbelief.

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[IM88]

"Gold standard" is a cultural norm, perhaps built up by our god-like image on TV. "Gold-standard" isn't science and we can hardly go around waving a gold banner to prove we are better than NPs. We need studies. I will find more, since everyone is underimpressed with the meta-analysis!

"Gold standard" is scientific. Medicine and science builds upon itself. The first drugs and tests for many medical conditions weren't great, but as new ones came along, they were still tested comparatively - that's the only way to definitively prove if the new is better than the old. Physicians are reasonably held as the gold standard based on the comprehensive training that they receive, combined with generations of experience as the sole providers of medical care. NPs may argue that the physician-led team model isn't the best, but that's the system that we have. In order to change the system, when patient's lives are at stake, we need to be scientific. When there is equipoise (whether there is currently equipoise for NPs providing a broad range of complex care independently is questionable), rigorous studies should be designed to try to determine an answer. Having a nursing lobby wave around poor quality studies and draw inappropriately broad claims that unsupervised NPs are better than physicians isn't scientific.

 

[dr zaius]

http://www.ncbi.nlm.nih.gov/pubmed/23772723
Patients co-managed by NPs and physicians did better than when they were managed by physicians alone
Percentage of care received by
APRN-MD MD
fall prevention 80% vs. 34%
urinary incontinence 66% vs 19%
dementia 59% vs. 38%

If you read that study there is no evidence of improved or even equivalent clinical outcomes. It wasn't even assessed. Nor were costs or resource utilization. Basically it was a study of who followed this printed out algorithm better.

Which subset of patients had better care for their COPD? Their CHF?

 

[IM88]

http://www.ncbi.nlm.nih.gov/pubmed/23772723
Patients co-managed by NPs and physicians did better than when they were managed by physicians alone

Your conclusion here does not match that of the paper you cited, and doesn't support your conclusion that NPs provide as good or better care than physicians. This is again a study of a specific type of practice and patient population (MD-NP comanagment of geriatric patients in community-based primary care ). This is precisely the situation for which most people agree that NPs and PAs can make a valuable contribution to medical care, but does not at all suggest that independent NPs are equivalent to physicians.

 

[JamesAK]

Your conclusion here does not match that of the paper you cited, and doesn't support your conclusion that NPs provide as good or better care than physicians. This is again a study of a specific type of practice and patient population (MD-NP comanagment of geriatric patients in community-based primary care ). This is precisely the situation for which most people agree that NPs and PAs can make a valuable contribution to medical care, but does not at all suggest that independent NPs are equivalent to physicians.

The huge multiple disciplinary metaanalysis did what you want done, but you don't have any reason for dismissing it except for ego, pretty sure.

 

[JamesAK]

Your conclusion here does not match that of the paper you cited, and doesn't support your conclusion that NPs provide as good or better care than physicians. This is again a study of a specific type of practice and patient population (MD-NP comanagment of geriatric patients in community-based primary care ). This is precisely the situation for which most people agree that NPs and PAs can make a valuable contribution to medical care, but does not at all suggest that independent NPs are equivalent to physicians.

If we physicians (or me on the way) are so great, why did care get better when NPs got involved?

 

[wxman393]

Depends what country the medical student is in--US it would be grad school, UK medical school is an undergraduate program from what I understand. Anybody know about other countries?

Medical school is technically undergraduate medical education. That's why residency is known as Graduate Medical Education (GME).

Source: Association of American Medical Colleges (AAMC)


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[dr zaius]

If we physicians (or me on the way) are so great, why did care get better when NPs got involved?

Define "care." Care is not outcomes. Care in this study was following this algorithm they created. They did not assess outcomes, and they acknowledge that in the study.

 

[Mansamusa]

http://www.ncbi.nlm.nih.gov/pubmed/23772723
Patients co-managed by NPs and physicians did better than when they were managed by physicians alone
Percentage of care received by
APRN-MD MD
fall prevention 80% vs. 34%
urinary incontinence 66% vs 19%
dementia 59% vs. 38%

http://www.medscape.com/viewarticle/723986 "care provided by NPs is as effective as, and no different from, that of physicians in terms of health status, treatment practices, and prescribing behavior. Moreover, NPs achieved consistently better results than their physician colleagues on measures of patient follow-up, consultation time, satisfaction, and the provision of screening, assessment, and counseling."

We all said that a team-based model is good. The other 1990-2008 study you posted also showed that team models are good....Doesn't say anything about whether or not NPs are prepared to practice independently

 

[Psai]

If we physicians (or me on the way) are so great, why did care get better when NPs got involved?

If we physicians LOL
Can we ban this joker already? It's so apparent that he's some sort of nursing student

 

[giantswing]

"Gold standard" is a cultural norm, perhaps built up by our god-like image on TV. "Gold-standard" isn't science and we can hardly go around waving a gold banner to prove we are better than NPs. We need studies. I will find more, since everyone is underimpressed with the meta-analysis!

You just outed yourself as a nurse.

 

[Mansamusa]

The huge multiple disciplinary metaanalysis did what you want done, but you don't have any reason for dismissing it except for ego, pretty sure.

I don't mean to be condescending, but I'm going to try to explain what you have been missing.

NP indendent practice rights= NPs practicing alone without physician oversight.

Healthcare team= MD and NPs (and everyone else) collaborating

Showing that a healthcare team of NPs and MDs produces better care =/= NPs do better on their own. But is does show that when NPs work with physician oversight, good healthcare happens.

 

[dr zaius]

I don't mean to be condescending, but I'm going to try to explain what you have been missing.

NP indendent practice rights= NPs practicing alone without physician oversight.

Healthcare team= MD and NPs (and everyone else) collaborating

Showing that a healthcare team of NPs and MDs produces better care =/= NPs do better on their own. But is does show that when NPs work with physician oversight, good healthcare happens.

Which I think most everyone would agree with.

 

[Matthew9Thirtyfive]

I am sorry that you see my posts as immature. I was merely asking people to show respect to others and stick with attacking the argument rather than the argue-er.

I understand that there are areas of the world where there are much bigger problems. That does not mean we can't be civil to each other here.

Except that no one was being disrespectful to women except maybe the guy implying that he needs to stand up for them.

 

[Mad Jack]

http://www.ncbi.nlm.nih.gov/pubmed/23772723
Patients co-managed by NPs and physicians did better than when they were managed by physicians alone
Percentage of care received by
APRN-MD MD
fall prevention 80% vs. 34%
urinary incontinence 66% vs 19%
dementia 59% vs. 38%

http://www.medscape.com/viewarticle/723986 "care provided by NPs is as effective as, and no different from, that of physicians in terms of health status, treatment practices, and prescribing behavior. Moreover, NPs achieved consistently better results than their physician colleagues on measures of patient follow-up, consultation time, satisfaction, and the provision of screening, assessment, and counseling."

Given that physicians spend half as long with their patients, that would show that physicians can do equally as well in half the time at best, and at worst that nurses require greater resources for less output (since they utilize the same amount of office space for half of the patient load compared to physicians). And this still doesn't get into study quality in the slightest lol. You clearly don't understand methodology or study design to an embarassing degree. You can't claim "equal" when you're seeing half the number of patients and likely a different mix of patients for greater amounts of time.

NPs clearly provide better results than a physician working alone, because collaboration is undoubtedly better than going it solo- that isn't something physicians doubt, it is that nurses perform as well as independent physicians when working under the same rules and such as independent physicians.

 

[JamesAK]

Given that physicians spend half as long with their patients, that would show that physicians can do equally as well in half the time at best, and at worst that nurses require greater resources for less output (since they utilize the same amount of office space for half of the patient load compared to physicians). And this still doesn't get into study quality in the slightest lol. You clearly don't understand methodology or study design to an embarassing degree. You can't claim "equal" when you're seeing half the number of patients and likely a different mix of patients for greater amounts of time.

NPs clearly provide better results than a physician working alone, because collaboration is undoubtedly better than going it solo- that isn't something physicians doubt, it is that nurses perform as well as independent physicians when working under the same rules and such as independent physicians.

We need a better insurance system so all health professionals can spend longer with their patients, including us. The meta-analysis was better directed at most of the concerns here

 

[IM88]

The huge multiple disciplinary metaanalysis did what you want done, but you don't have any reason for dismissing it except for ego, pretty sure.

The metaanalysis that you cite looked at physician + NP teams... Again, this doesn't provide any evidence that NPs provide as good or better care than physicians. I don't think people are debating whether NPs and other physician extenders have a valuable place in caring for patients. We need to better understand the capabilities of these physician extenders without compromising care or putting patients at risk. For example, one interpretation of these collaborative studies could simply be that more care = better outcomes, such that 5mins with MD + 15 mins with NP is better than 5 minutes with MD alone. Is 20 minutes with an MD better than 5 MD + 15 NP? Is 15 minutes with an unsupervised NP better than 15 minutes with a physician in terms of outcomes and resource utilization for equivalently sick patients? That's what really needs to be determined before you can start making claims that NPs provide "equivalent" care.

 

[JamesAK]

You just outed yourself as a nurse.

If you keep saying it over and over again maybe it will come true. Have you no nurse friends?

 

[JamesAK]

The metaanalysis that you cite looked at physician + NP teams... Again, this doesn't provide any evidence that NPs provide as good or better care than physicians. I don't think people are debating whether NPs and other physician extenders have a valuable place in caring for patients. We need to better understand the capabilities of these physician extenders without compromising care or putting patients at risk. For example, one interpretation of these collaborative studies could simply be that more care = better outcomes, such that 5mins with MD + 15 mins with NP is better than 5 minutes with MD alone. Is 20 minutes with an MD better than 5 MD + 15 NP? Is 15 minutes with an unsupervised NP better than 15 minutes with a physician in terms of outcomes and resource utilization for equivalently sick patients? That's what really needs to be determined before you can start making claims that NPs provide "equivalent" care.

Well, I hope you carry out such a study. But you may want to reconsider use of the term "physician extenders." They're aren't like some artificial limb wired to our brains--they have their own licenses and make their own decisions...

 

[ProfMD]

Except that no one was being disrespectful to women except maybe the guy implying that he needs to stand up for them.

Your post about women / girls is not the only uncivil or disrespectful post on this forum.

In fact, I concede that post may not be disrespectful at all.

 

[IM88]

they have their own licenses and make their own decisions...

But it isn't yet clear that without MD oversight they make safe decisions that efficiently make use of the available resources. When that happens we can re-evaluate the term "physician extender."

 

[Psai]

If you keep saying it over and over again maybe it will come true. Have you no nurse friends?

New nursing students and people intending to go into np school seem to love coming here and do exactly what you're doing. Posting nonsense studies, not listening to arguments, just blathering on and on about their talking points that we've heard and dismissed a million times before. They also just bump their own thread a million times and ignore everything else.

Pretending to be a medical student when you're not is against the website's tos although mods seem not to care.

 

[giantswing]

If you keep saying it over and over again maybe it will come true. Have you no nurse friends?

No. Why?

 

[JamesAK]

But it isn't yet clear that without MD oversight they make safe decisions that efficiently make use of the available resources. When that happens we can re-evaluate the term "physician extender."

You don't see how that's offensive to people who actually have an education and aren't just mindless robots carrying out your commands?

 

[Mad Jack]

Well, I hope you carry out such a study. But you may want to reconsider use of the term "physician extenders." They're aren't like some artificial limb wired to our brains--they have their own licenses and make their own decisions...

I prefer the term "advanced nurse" myself. I'm going to try to make that a thing, because "provider" is a nonsense term that should be replaced by something that denotes their actual position, rather than a generic term for anyone that cares for a patient in any capacity.

 

[Mad Jack]

You don't see how that's offensive to people who actually have an education and aren't just mindless robots carrying out your commands?

They are physician extenders- force multipliers that allow one physician to oversee more patients than would otherwise be possible in a hospital or practice. They extend the ability of a physician to care for a larger number of people. That is what they were originally utilized for, and that is what studies show the best outcomes coming from.

 

[JamesAK]

New nursing students and people intending to go into np school seem to love coming here and do exactly what you're doing. Posting nonsense studies, not listening to arguments, just blathering on and on about their talking points that we've heard and dismissed a million times before. They also just bump their own thread a million times and ignore everything else.

Pretending to be a medical student when you're not is against the website's tos although mods seem not to care.

T

They are physician extenders- force multipliers that allow one physician to oversee more patients than would otherwise be possible in a hospital or practice. They extend the ability of a physician to care for a larger number of people. That is what they were originally utilized for, and that is what studies show the best outcomes coming from.

They were "originally utilized" to see people in rural areas, where physicians have no interest in practicing. And I know it makes us feel good to think that we are caring for 4 times as many patients if we work with NPs, but in fact they care for their own patients and maybe consult with physicians every so often--as good physicians consult with their NP colleagues when confronted with a matter outside their area of expertise

 

[dr zaius]

I do indeed consult my NP colleagues when I can't figure out a patient's fall risk or if their call bell is or is not within reach.

 

[Psai]

T


They were "originally utilized" to see people in rural areas, where physicians have no interest in practicing. And I know it makes us feel good to think that we are caring for 4 times as many patients if we work with NPs, but in fact they care for their own patients and maybe consult with physicians every so often--as good physicians consult with their NP colleagues when confronted with a matter outside their area of expertise

Nope. NPs were advertised as rural providers just like everyone else who is looking to push into medicine. However, they go into the same areas and the same fields as physicians do for the same reasons. And when would a doctor ever consult an np? Physicians consult their physician colleagues who are experts in their field. Midlevels working in specialty fields are for followup and writing consult notes on behalf of the physician, not seeing a patient independently and providing their own recommendations.

 

[ProfMD]

T


They were "originally utilized" to see people in rural areas, where physicians have no interest in practicing. And I know it makes us feel good to think that we are caring for 4 times as many patients if we work with NPs, but in fact they care for their own patients and maybe consult with physicians every so often--as good physicians consult with their NP colleagues when confronted with a matter outside their area of expertise

Here, I do need to disagree. Physicians do not consult with APNs as a general rule.

 

[JamesAK]

Here, I do need to disagree. Physicians do not consult with APNs as a general rule.

Yet my NP friends say the physicians they work with consult them on wound care, patients with complicated education and care needs...

 

[ProfMD]

Yet my NP friends say the physicians they work with consult them on wound care, patients with complicated education and care needs...

Assist with care would be a better way to put it. It is true that wound care services are often staffed by wound care nurses (or wound care PTs) but still the ultimate authorities are physicians (plastic surgery, sometimes burn surgery or general surgery).

Complicated education and care needs? This sounds like care coordination which is a pretty standard nursing role. However, physicians typically prescribe the care to be coordinated.

 

[IsWhat]

Where do these militant NPs come from? I work at a top 10 academic medical center with one of the better NP programs around (in an independent practice state), and every NP I work with knows their place in the pecking order. The knowledge level between the attendings I work for and their NPs isn't even in the same ballpark...

 

[Psai]

Yet my NP friends say the physicians they work with consult them on wound care, patients with complicated education and care needs...

I've only seen wound care done by specially trained wound care rns. Education needs is like teaching a patient's family how to care for the gastrostomy tube. That's not a consult.

 

[deleted564680]

I was going to post replies but then realized I had about 7 quotes to respond to from a certain poster and it's just not worth it. Ignorance truly is bliss it seems.

Welcome to the new America where everyone who disagrees with you is racist/sexist and opinions >>> facts. A big shout out thank you to our college professors living in idealistic cloud-land who are instilling these wonderful skills in our young, impressionable citizens. Rock on crusaders!

 

[TBV]

God this JamesAK guy is worse than AIDS.

 

[Moose A Moose]

For all of the "abused nurses" and bleeding hearts out there, I called this in for you...

 

[jqueb29]

http://www.ncbi.nlm.nih.gov/pubmed/23772723
Patients co-managed by NPs and physicians did better than when they were managed by physicians alone
Percentage of care received by
APRN-MD MD
fall prevention 80% vs. 34%
urinary incontinence 66% vs 19%
dementia 59% vs. 38%

http://www.medscape.com/viewarticle/723986 "care provided by NPs is as effective as, and no different from, that of physicians in terms of health status, treatment practices, and prescribing behavior. Moreover, NPs achieved consistently better results than their physician colleagues on measures of patient follow-up, consultation time, satisfaction, and the provision of screening, assessment, and counseling."

Are you even scientifically literate? This study is a retrospective chart review, not a randomized control trial. It completely fails to account for a major confounder: easier cases are going to be co-managed, while harder cases are going to be handled only by the expert doctor. And guess which cases are more likely to have a positive outcome? As previously stated several times in this thread, a legitimate study would assign similar patient groups to receive care by either only NP's or only MD's, not any of this intermingling where NP incompetence can be masked by an MD looking things over and saving them. Such a study would remove the MD safety net from NP's, revealing them to be less effective. And such a study would also have them dealing with more complicated cases all by themselves (cases that only physicians handle), which would definitely further reveal deficiencies. But that study will never happen because we know that it would be putting patients at risk.

 

[JamesAK]

Where do these militant NPs come from? I work at a top 10 academic medical center with one of the better NP programs around (in an independent practice state), and every NP I work with knows their place in the pecking order. The knowledge level between the attendings I work for and their NPs isn't even in the same ballpark...

Who is militant?

And such contempt!

 

[67552931811]

T


They were "originally utilized" to see people in rural areas, where physicians have no interest in practicing. And I know it makes us feel good to think that we are caring for 4 times as many patients if we work with NPs, but in fact they care for their own patients and maybe consult with physicians every so often--as good physicians consult with their NP colleagues when confronted with a matter outside their area of expertise

I have seen or experienced this literally 0 times in my life and I've been around medicine probably longer than you have been alive.

 

[JamesAK]

I have seen or experienced this literally 0 times in my life and I've been around medicine probably longer than you have been alive.

So sad for you. You must be wearing some serious blinders

 

[Mansamusa]

So sad for you. You must be wearing some serious blinders

Hey, more irony

 

[Stagg737]

Where do these militant NPs come from? I work at a top 10 academic medical center with one of the better NP programs around (in an independent practice state), and every NP I work with knows their place in the pecking order. The knowledge level between the attendings I work for and their NPs isn't even in the same ballpark...

Take a stroll over to allnurses.com and poke around the threads there and you'll find hundreds. I've also talked to several nursing students in person who referred to their schools as "med schools" without saying they were nursing students to make people think they were in med school (you know, the kind that trains physicians). The worst I saw was a co-worker who was fired from their internship for putting "_____ Medical College" on their CV and pretending they were going to be a physician when they were actually taking classes to be a CNA. It's sad how many people want prestige or recognition for work they never did instead of just doing their job well and getting respect that way.

 

[67552931811]

So sad for you. You must be wearing some serious blinders

Lol. You are one obtuse individual. Enjoy your nursing career, brother.

 

[giantswing]

You don't see how that's offensive to people who actually have an education and aren't just mindless robots carrying out your commands?

They're called orders for a reason.

 

[Matthew9Thirtyfive]

Take a stroll over to allnurses.com and poke around the threads there and you'll find hundreds. I've also talked to several nursing students in person who referred to their schools as "med schools" without saying they were nursing students to make people think they were in med school (you know, the kind that trains physicians). The worst I saw was a co-worker who was fired from their internship for putting "_____ Medical College" on their CV and pretending they were going to be a physician when they were actually taking classes to be a CNA. It's sad how many people want prestige or recognition for work they never did instead of just doing their job well and getting respect that way.

They made it illegal to do that for a lot of professions. There are hundreds of jokers claiming to be Navy SEALs in bars out here. I've taught my civilian friends what to ask to expose them. None of my team buddies would ever tell anyone they just met what they do. OPSEC anyone?

 

[IsWhat]

They made it illegal to do that for a lot of professions. There are hundreds of jokers claiming to be Navy SEALs in bars out here. I've taught my civilian friends what to ask to expose them. None of my team buddies would ever tell anyone they just met what they do. OPSEC anyone?

Actually had a guy not to long ago try to pull that on me and my Marine buddy. It didn't turn out so well for him when he couldn't tell us what BUD/S class he was in...

 

[Matthew9Thirtyfive]

Actually had a guy not to long ago try to pull that on me and my Marine buddy. It didn't turn out so well for him when he couldn't tell us what BUD/S class he was in...

That's exactly what I tell them to ask. And if it sounds fishy or they can't say, bull**** alert. I really want to turn them over to Don Shipley, but I haven't gotten around to it.

 

[The Kraken]

Please show me the citation.

There has never been an RCT measuring outcomes between cohorts of physicians and non-supervised NPs. Until then, stop claiming research shows their care is "just as good." It is not.

Well there's this from 2000, but yes, there isn't a ton of great independent v. independent care: http://www.ncbi.nlm.nih.gov/pubmed/10632281

But what do you actually expect for better data? A massive study comparing who kept a1c's and systolic bps lowest in ambulatory primary care? Lol. Of course there will be minimal difference because 99% of urgent care/walk in clinic patients that are followed are going to be fine seeing an NP or MD/DO. For every superstar provider, NP or physician, that finds the oddball will be a handful of auto-piloting peers with the same 2 letters that will miss it.

 

[ShibaInu26]

Topic: "Flying scalpels and the future of healthcare"

Discussion: Nurses suck - using girl = bad

Response: Blame liberals

Edit: Just catching everyone up with the thread so far.

because.....logic. Oh, internet.....