How do we stop nurse practitioners?

[FNP_Blix]

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That is very bright eyed of you to have that perspective. Here is part of the reality I saw during my FM rotation:

1. There is a massive and complex cost issue that isn't solved with number or type of provider. More MD or NP will not solve the problem alone. FM physicians can typically provide more extensive knowledge and services due to their training to justify a higher income. NPs provide some overlapping services but are rarely full-scope (what most people would call "quality care" from an FM point of view)...it is simply impossible for either MD or NP to practice full-scope medicine without relying on specialist services at some point, and those services are costly to everyone, including the physician. It always costs more for FM providers to accept the liability of providing these extra services, and nobody will thank you or feel sorry for you for accepting that responsibility. It may be more cost-effective to simply not provide those services (ex: FM-OB).

2. The government is reluctant or completely unwilling to take on the costs. Where available, medicare and medicaid usually want providers to fight a never ending paper battle. The paper battle involves spending twice as long with patients to receive below average compensation--you could bankrupt yourself. It is a path of high resistance, and many, including NPs, are unwilling that fight against that resistance. That path of less resistance involves moderate-high income patients with insurance or a concierge model if your community is interested. Speaking practically, the government would appreciate it if you would see more rich patients that can pay for their medical services so that they could go on ignoring a large indigent population.

3. The indigent population is typically uneducated, nonadherent, have more healthcare needs on average due to their situation, and are completely unwilling to accept any costs. This could mean spending extra time talking to a wall, and usually involves spending extra resources and money on patients that simply wont get better. It is an equity battle, which the government understands and is also why they triage payment. It usually comes out of the pocket of the physician or nurse who is more willing than the patient to create and foster health.

When you put in the 30 years of dealing with this constantly, people will respect that talk. I do think that FM is "noble", but I also understand the 30 year FM who discourages students from going in. It is like volunteering to serve in the infantry during the Vietnam war because "Communism". Literally nobody wants you there, except the government. The reality is that your ideal transcends the political and economic landscape insofar as it is not what anybody wants of healthcare right now. Ironically, you might be able to do more "good" than you think by specializing and taking indigent patients...in that sense, military medicine is perfect for you. But I don't see the addition of NPs significantly impacting the issues above, and may actually serve as an impediment in all three cases (increasing costs by providing subpar or inefficient services).



No. There is a wealth of data that show that CRNAs take on less sick patients and less complex cases to the same outcome as an anesthesiologist. I do not know if any CRNAs are taking on complex cases at a university level without anesthesiologist oversight. The hospitals and states that these independent practitioners serve typically run uncomplicated cases. You cannot be a cherry picker and accept responsibility to provide the full scope of services that a highly focused consultant specialty says it provides. CRNAs are interested in taking the easy bread and butter cases that all anesthetic providers must live and earn off of ; in their own words, they "do not want to be physicians or anesthesiologists." In the case of the very proficient CRNAs, there is the same problem that NPs have which is there is no consistency from one CRNA to the next. While that may be acceptable for NPs, that is unacceptable for licensure in providing all anesthetic services that would justify independent practice.

So whats the solution right NOW? Lets remove all mid-levels tomorrow & see what happens?? I get what your saying and you make very valid points. But what the heck are we supposed to do now about the issues that face healthcare. Mid-levels are the options we have now to increase access, and provide at the very least basic healthcare services to millions of people. That is why I am for independent practice. You cannot have an NP, CRNA or CNM 100-200 miles away from the nearest hospital or paired with a physician who charges an arm and a leg for "collaboration", when that provider is getting paid pennies on the dollar already to see indigent populations. The restrictions, a majority of the time, are useless and create an extra bottle neck for the providers and the patients they serve.

 

[atomheart]

So whats the solution right NOW? Lets remove all mid-levels tomorrow & see what happens?? I get what your saying and you make very valid points. But what the heck are we supposed to do now about the issues that face healthcare. Mid-levels are the options we have now to increase access, and provide at the very least basic healthcare services to millions of people. That is why I am for independent practice. You cannot have an NP, CRNA or CNM 100-200 miles away from the nearest hospital or paired with a physician who charges an arm and a leg for "collaboration", when that provider is getting paid pennies on the dollar already to see indigent populations. The restrictions, a majority of the time, are useless and create an extra bottle neck for the providers and the patients they serve.

Cost = Access. Interestingly, you're looking at the problem from the point of view that doctors and nurses decrease costs as opposed to provide value. This cost problem is not solved from the provider side at all. Providers are the workers that create value, but they have no say in costs. Costs are determined by the middlemen: government-insurance-lawyers-hospitals. More importantly costs are not a "problem" from the standpoint that medicine is a business, and profits will be maximized from all angles. Mid-level providers are a profit incentive in this scheme: hospitals can make back triple the yearly salary of a hospital PA for example. If there were no profit incentives to mid-levels they wouldn't exist, and therefore they will always exist if they can add to the bottom line.

The concept of "access" in medicine has misled too many to going into the field for the wrong reasons. Many patients don't need a doctor or anyone else. Many acute conditions resolve on their own with no mention of the added problems we cause by trying to do something about them. To add, medicine is mostly about the revolving door of profiting off the same patients that won't get better from their chronic conditions--milking the insurance cow. Finally, the access that primary care provides is rarely what the patient wants or needs. What they need is a less expensive MRI to determine if a chronic headache could be a tumor, for example. Once again, more mid-levels doesn't solve the issue.

I would also add that CRNAs are originally viewed as extenders of the anesthesiology profession due to more surgeries performed than anesthesiologists. However, CRNAs have always rejected that label because it creates existential tension in that profession, as if they could just disappear if fewer surgeries happened or more anesthesiologists existed. Ironically, the perspective shift to "access provider" has caused all of us to lose focus on the truth: neither physicians or variants of mid-levels would exist if the persons in charge of the purse strings couldn't find financial justification for their existence.

 

[jdav_7]

Cost = Access. Interestingly, you're looking at the problem from the point of view that doctors and nurses decrease costs as opposed to provide value. This cost problem is not solved from the provider side at all. Providers are the workers that create value, but they have no say in costs. Costs are determined by the middlemen: government-insurance-lawyers-hospitals. More importantly costs are not a "problem" from the standpoint that medicine is a business, and profits will be maximized from all angles. Mid-level providers are a profit incentive in this scheme: hospitals can make back triple the yearly salary of a hospital PA for example. If there were no profit incentives to mid-levels they wouldn't exist, and therefore they will always exist if they can add to the bottom line.

The concept of "access" in medicine has misled too many to going into the field for the wrong reasons. Many patients don't need a doctor or anyone else. Many acute conditions resolve on their own with no mention of the added problems we cause by trying to do something about them. To add, medicine is mostly about the revolving door of profiting off the same patients that won't get better from their chronic conditions--milking the insurance cow. Finally, the access that primary care provides is rarely what the patient wants or needs. What they need is a less expensive MRI to determine if a chronic headache could be a tumor, for example. Once again, more mid-levels doesn't solve the issue.

I would also add that CRNAs are originally viewed as extenders of the anesthesiology profession due to more surgeries performed than anesthesiologists. However, CRNAs have always rejected that label because it creates existential tension in that profession, as if they could just disappear if fewer surgeries happened or more anesthesiologists existed. Ironically, the perspective shift to "access provider" has caused all of us to lose focus on the truth: neither physicians or variants of mid-levels would exist if the persons in charge of the purse strings couldn't find financial justification for their existence.

I hear what you're saying in the first two paragraphs, but you're not actually saying anything factual. The idea that we need to MRI everyone with headaches to check for a tumor is literally a prime example of why we're having discussions about quality and access in the first place. MRIs and other diagnostic tools are largely used as a crutch to either a) avoid prolonging pain for cases that could easily be diagnosed clinically with an extra few hours of observation (for instance, a CT abdomen is completely unnecessary for diagnosing appendicitis but we all know rads is getting called in anyway) b) to save clinicians from malpractice lawsuits. There are other peripheral reasons, but those are the two big ones. Also, the idea that recurrent patients are somehow profitable is ludicrous. Hospital readmissions cost $12B in Medicare funding in 2016 (I think, could have been 2015) alone. Since Medicare pays pennies on the dollar for reimbursement, everyone loses on recurring patients. There are rare examples of people with PHI recurrently using health resources and thus profiting hospital systems, but just from the nature of SES-associated health disparities they are the minority rather than the rule. I think you make an excellent point about what providers are actually bringing to the table, but the rest is just jargon that isn't backed by data.

 

[FNP_Blix]

Cost = Access. Interestingly, you're looking at the problem from the point of view that doctors and nurses decrease costs as opposed to provide value. This cost problem is not solved from the provider side at all. Providers are the workers that create value, but they have no say in costs. Costs are determined by the middlemen: government-insurance-lawyers-hospitals. More importantly costs are not a "problem" from the standpoint that medicine is a business, and profits will be maximized from all angles. Mid-level providers are a profit incentive in this scheme: hospitals can make back triple the yearly salary of a hospital PA for example. If there were no profit incentives to mid-levels they wouldn't exist, and therefore they will always exist if they can add to the bottom line.

The concept of "access" in medicine has misled too many to going into the field for the wrong reasons. Many patients don't need a doctor or anyone else. Many acute conditions resolve on their own with no mention of the added problems we cause by trying to do something about them. To add, medicine is mostly about the revolving door of profiting off the same patients that won't get better from their chronic conditions--milking the insurance cow. Finally, the access that primary care provides is rarely what the patient wants or needs. What they need is a less expensive MRI to determine if a chronic headache could be a tumor, for example. Once again, more mid-levels doesn't solve the issue.

I would also add that CRNAs are originally viewed as extenders of the anesthesiology profession due to more surgeries performed than anesthesiologists. However, CRNAs have always rejected that label because it creates existential tension in that profession, as if they could just disappear if fewer surgeries happened or more anesthesiologists existed. Ironically, the perspective shift to "access provider" has caused all of us to lose focus on the truth: neither physicians or variants of mid-levels would exist if the persons in charge of the purse strings couldn't find financial justification for their existence.

Not exactly. Cost does not only equal access. Its only a part of the issue, but not all of it. No one can or want's to attempt to profit off of a patient with chronic illness. As was said earlier, it is not profitable to do that (e.g., hospital readmissions become very expensive for hospitals). And perhaps, ARNPs are less money, and so I can see how the government and insurance companies could potentially take advantage of that. But the truth is, THEY DONT. NPs cannot bill most private insurance companies or be listed as a primary care providers. Thus, a loss in terms of a potential market to be tapped into. NPs are vastly underutilized, so your argument just doesn't hold up.

Also, NPs exist because of their quality and value, not because of dollars. They have existed since since the early 20th century, and had a role in providing care where patient's could not otherwise reach a physician or pay for his/her expensive services. NPs are still doing this today in both urban and rural areas.

Regarding your other point on overprescribing and over-treating being an issue, I would point out that physicians are the epitome of someone that is overprescribing (i.e., ABX for viral illnesses or "milking" profits for those with chronic pain). For example, the whole epidemic of opioid abuse and bacterial resistance has been largely perpetuated by physicians, not nurses. We are trained to change that trajectory and prevent diseases through health promotion.

What your failing to see is that access is largely about the number of physicians and healthcare providers in relation to the entire population. You (doctors) cannot do it all alone. Restricting a NP from being able to order for example, a diabetic boot because he/she needs a physician's signature is absolutely ridiculous. That is why we are able to practice independently in 20 states and D.C. Because the government sees that (my point) to be true.

You can argue all day about what APNs (i.e., CRNA, NP, CNM) should and should not do, in terms of scope. But the bottom line is we need more providers that can perform more services and at a lower cost. We need them, and we need them NOW. Will physicians be able to answer the call? That remains to be seen. There is over 320 million Americans and our population is getting older. A whole generation of physicians and nurses are retiring soon. So advance practice nurses are going to have a huge role in mitigating all this.

 

[deleted480308]

Not exactly. Cost does not only equal access. Its only a part of the issue, but not all of it. No one can or want's to attempt to profit off of a patient with chronic illness. As was said earlier, it is not profitable to do that (e.g., hospital readmissions become very expensive for hospitals). And perhaps, ARNPs are less money, and so I can see how the government and insurance companies could potentially take advantage of that. But the truth is, THEY DONT. NPs cannot bill most private insurance companies or be listed as a primary care providers. Thus, a loss in terms of a potential market to be tapped into. NPs are vastly underutilized, so your argument just doesn't hold up.

Also, NPs exist because of their quality and value, not because of dollars. They have existed since since the early 20th century, and had a role in providing care where patient's could not otherwise reach a physician or pay for his/her expensive services. NPs are still doing this today in both urban and rural areas.

Regarding your other point on overprescribing and over-treating being an issue, I would point out that physicians are the epitome of someone that is overprescribing (i.e., ABX for viral illnesses or "milking" profits for those with chronic pain). The whole epidemic of opioid abuse and bacterial resistance has been largely perpetuated by physicians, not nurses. We are trained to change that trajectory and prevent diseases through health promotion.

What your failing to see is that access is largely about the number of physicians and healthcare providers in relation to the entire population. You (doctors) cannot do it all alone. Restricting a NP from being able to order for example, a diabetic boot because he/she needs a physician's signature is absolutely ridiculous. That is why we are able to practice independently in 20 states and D.C. Because the government sees that (my point) to be true.

You can argue all day about what APNs (i.e., CRNA, NP, CNM) should and should not do, in terms of scope. But the bottom line is we need more providers that can perform more services and at a lower cost. We need them, and we need them NOW. Will physicians be able to answer the call? That remains to be seen. There is over 320 million Americans and our population is getting older. A whole generation of physicians and nurses are retiring soon. So advance practice nurses are going to have a huge role in mitigating all this.

you can't use lower cost as part of your excuse for letting lesser trained people work independently........the NPs have already started pushing for equal pay and have managed to get that into law in Oregon

 

[FNP_Blix]

you can't use lower cost as part of your excuse for letting lesser trained people work independently........the NPs have already started pushing for equal pay and have managed to get that into law in Oregon

Are they providing the same services?

 

[deleted480308]

Are they providing the same services?

not at all.....

(and I'm overexaggerating here for effect) in the same way that I would pay a surgeon to take out my appendix. I'm not really just paying for the physical removal of the appendix. I'm paying for the high level of expertise to decide if it needs to go and to handle any thing during the surgery with the highest possible level of success. I could also pay my mailman to take out an appendix. Far less expertise, different risks and less ability to handle anything odd that happens.

The mailman might try to make the argument that they deserve the same money because both are taking out an appendix but both know good and well they aren't offering the same service.

And furthermore, if the mailman got a law passed that they couldn't be paid less for taking out the appendix than an actual surgeon.......the mailman doesn't get to go on message boards and dishonestly claim that cost is a justification for allowing an unqualified mailman to take out an appendix

 

[FNP_Blix]

not at all.....

(and I'm overexaggerating here for effect) in the same way that I would pay a surgeon to take out my appendix. I'm not really just paying for the physical removal of the appendix. I'm paying for the high level of expertise to decide if it needs to go and to handle any thing during the surgery with the highest possible level of success. I could also pay my mailman to take out an appendix. Far less expertise, different risks and less ability to handle anything odd that happens.

The mailman might try to make the argument that they deserve the same money because both are taking out an appendix but both know good and well they aren't offering the same service.

And furthermore, if the mailman got a law passed that they couldn't be paid less for taking out the appendix than an actual surgeon.......the mailman doesn't get to go on message boards and dishonestly claim that cost is a justification for allowing an unqualified mailman to take out an appendix

The answer is that they do provide a lot of the same services. NPs are trained to perform medical services like physicians. So they are qualified in their given scope. Thus deserve same pay for services they perform equally.

 

[deleted480308]

The answer is that they do provide a lot of the same services. NPs are trained to perform medical services like physicians. So they are qualified.

no. no, they are not.

 

[atomheart]

I hear what you're saying in the first two paragraphs, but you're not actually saying anything factual. The idea that we need to MRI everyone with headaches to check for a tumor is literally a prime example of why we're having discussions about quality and access in the first place. MRIs and other diagnostic tools are largely used as a crutch to either a) avoid prolonging pain for cases that could easily be diagnosed clinically with an extra few hours of observation (for instance, a CT abdomen is completely unnecessary for diagnosing appendicitis but we all know rads is getting called in anyway) b) to save clinicians from malpractice lawsuits. There are other peripheral reasons, but those are the two big ones. Also, the idea that recurrent patients are somehow profitable is ludicrous. Hospital readmissions cost $12B in Medicare funding in 2016 (I think, could have been 2015) alone. Since Medicare pays pennies on the dollar for reimbursement, everyone loses on recurring patients. There are rare examples of people with PHI recurrently using health resources and thus profiting hospital systems, but just from the nature of SES-associated health disparities they are the minority rather than the rule. I think you make an excellent point about what providers are actually bringing to the table, but the rest is just jargon that isn't backed by data.

The main purpose of using a diagnostic tool is to diagnose. That's not peripheral. You need a diagnosis if you're a specialist treating a condition and would prefer reimbursement. You don't need an MRI for everyone with h/a, I never said that. What I said before is no physician practices full scope without relying on other services at some point. I would disagree that radiology services are largely used as a crutch, though they certainly can be.

I get that you want data, and that's fine. I'm not going to find it for you. Instead I'm going to ask you to find me data that disproves my point that providers aren't the main cause of increasing costs in medicine.

 

[FNP_Blix]

no. no, they are not.

The state of Oregon doesn't agree with you...and maybe your right, we do many services better.

 

[deleted480308]

The state of Oregon doesn't agree with you...and maybe your right, we do many services better.

we clearly haven't interacted much if you think I consider the opinion of legislators to have an intrinsic alignment with truth

 

[atomheart]

No one can or want's to attempt to profit off of a patient with chronic illness.

Regarding your other point on overprescribing and over-treating being an issue, I would point out that physicians are the epitome of someone that is overprescribing (i.e., ABX for viral illnesses or "milking" profits for those with chronic pain). For example, the whole epidemic of opioid abuse and bacterial resistance has been largely perpetuated by physicians, not nurses. We are trained to change that trajectory and prevent diseases through health promotion.

What your failing to see is that access is largely about the number of physicians and healthcare providers in relation to the entire population. You (doctors) cannot do it all alone. Restricting a NP from being able to order for example, a diabetic boot because he/she needs a physician's signature is absolutely ridiculous. That is why we are able to practice independently in 20 states and D.C. Because the government sees that (my point) to be true.
......
The bottom line is we need more providers that can perform more services and at a lower cost. We need them, and we need them NOW. Will physicians be able to answer the call? That remains to be seen. There is over 320 million Americans and our population is getting older. A whole generation of physicians and nurses are retiring soon. So advance practice nurses are going to have a huge role in mitigating all this.

FNP,

Managing chronic disease is the bread and butter of FM and IM. Unless you're practicing at an urgent care. If your definition of access to care is an UC on every corner you're going to have a fulfilling career. And i predict you will have a long and fulfilling career in which you see medical costs continue to rise despite more and cheaper providers.

Fine don't buy into the argument, but don't sell me the same bill that my school used to attract applicants. Every DO and international school uses those same lines. DOs and IMGs have been around longer and are equally committed to primary care. They are also trained on ABX resistance and opioid abuse. Must be a failure of physicians that has led to all problems in medicine. It is nice to have other medical providers now so that the blame can be equally distributed.

 

[jdav_7]

The main purpose of using a diagnostic tool is to diagnose. That's not peripheral. You need a diagnosis if you're a specialist treating a condition and would prefer reimbursement. You don't need an MRI for everyone with h/a, I never said that. What I said before is no physician practices full scope without relying on other services at some point. I would disagree that radiology services are largely used as a crutch, though they certainly can be.

I get that you want data, and that's fine. I'm not going to find it for you. Instead I'm going to ask you to find me data that disproves my point that providers aren't the main cause of increasing costs in medicine.

Costs, charges, and revenues for hospital diagnostic imaging procedures: differences by modality and hospital characteristics. - PubMed - NCBI

There's a great starting point for you. Next, follow the yellow brick road on IMRT for prostate cancer self refer, breast cancer screening, appendicitis screening, and any other procedure at your whim. You would think that diagnostic procedures would be used to diagnose, but we unfortunately have created a system in which diagnostic imagery is a huge bread-winner for hospitals. Same for da Vinci robotics (huge trove of data on those outcomes). It's really, really sad.

 

[KGflyboy]

The answer is that they do provide a lot of the same services. NPs are trained to perform medical services like physicians. So they are qualified in their given scope. Thus deserve same pay for services they perform equally.

This is the sticking point in the conversation. You think NPs are "trained to perform medical services like physicians." However, that couldn't be farther from the truth. NPs are not trained like physicians. How much time is spent reading EKGs in NP school. Interpreting imaging studies? Delivering babies? Residency trained family medicine physicians can do all of these things and much more. Many of them don't use all of these skills in practice, but that's by choice. They had the training.

Sent from my ONEPLUS A5000 using Tapatalk

 

[atomheart]

Costs, charges, and revenues for hospital diagnostic imaging procedures: differences by modality and hospital characteristics. - PubMed - NCBI

There's a great starting point for you. Next, follow the yellow brick road on IMRT for prostate cancer self refer, breast cancer screening, appendicitis screening, and any other procedure at your whim. You would think that diagnostic procedures would be used to diagnose, but we unfortunately have created a system in which diagnostic imagery is a huge bread-winner for hospitals. Same for da Vinci robotics (huge trove of data on those outcomes). It's really, really sad.

I did a little bit of searching and read your article, but I'm confused how adding mid-level providers will solve hospital billing for diagnostics. I feel like this discussion is going down a different pathway that finds physicians at fault for a system that incentivizes medical profiteering. Yet there are many more players than just physicians in the industry making profit. I feel like if my example was about expensive drugs or medical devices you would still blame physicians.

I think you're trying to argue that a socialized or centralized system is better for costs which i don't dispute. I argue that adding more mid-levels has little to do with cost direction. Where does medical training fit in the picture?

 

[FNP_Blix]

Im sorry but pay for performance measures would indicate a different picture. Regardless of the fact that you have an MD behind your name, if you do a crappy job, why should you get paid well? NPs consistently show to do just as a good a job as physicians, particularly in areas that matter financially (i.e., reducing hospital readmissions, overall mortality risks, etc.) This all translates to dollars and is why nurses get paid well.

 

[deleted480308]

Im sorry but pay for performance measures would indicate a different picture. Regardless of the fact that you have an MD behind your name, if you do a crappy job, why should you get paid well? NPs consistently show to do just as a good a job as physicians, particularly in areas that matter financially (i.e., reducing hospital readmissions, overall mortality risks, etc.) This all translates to dollars and is why nurses get paid well.

Again.....they haven't been shown to do that

 

[jdav_7]

I did a little bit of searching and read your article, but I'm confused how adding mid-level providers will solve hospital billing for diagnostics. I feel like this discussion is going down a different pathway that finds physicians at fault for a system that incentivizes medical profiteering. Yet there are many more players than just physicians in the industry making profit. I feel like if my example was about expensive drugs or medical devices you would still blame physicians.

I think you're trying to argue that a socialized or centralized system is better for costs which i don't dispute. I argue that adding more mid-levels has little to do with cost direction. Where does medical training fit in the picture?

Yes, you're right. I think we are more in agreement than it seems. I don't disagree that mid levels have little effect on cost. They're more of a solution to access than cost. Cost, access and quality are intimately related though, so hard to delineate which is which.

Blaming physicians is not my intent at all - after all, I'm going to medical school next year. My point is that we have a system that incentivizes all providers - not just physicians - to make bad decisions from a medical and financial perspective. I don't believe saturating the market with mid-levels is the best solution, but is perhaps the only stop-gap option we have in eliminating access issues. Personally, I'm all for upping NP training with perhaps an extra year or two of residency and then using them in eliminating health disparities until legislation is amended to put patients first.

 

[KGflyboy]

Im sorry but pay for performance measures would indicate a different picture. Regardless of the fact that you have an MD behind your name, if you do a crappy job, why should you get paid well? NPs consistently show to do just as a good a job as physicians, particularly in areas that matter financially (i.e., reducing hospital readmissions, overall mortality risks, etc.) This all translates to dollars and is why nurses get paid well.

The studies you are relying on here don't support the conclusions you are asserting. Your statement is inaccurate. NPs have not been shown to do any of the things you just stated.

 

[FNP_Blix]

Yes actually the data shows this. Not only are ARNPs just as good as physicians in various outcomes of measure, but score even better. They have proven, time and time again to be cost effective and reduce cost of care. They have been studied extensively in countries beyond the U.S.A. and a vast majority of the data published proves their efficacy. ARNPs, CNMs, CNSs and CRNAs alike have been studied similarly and with similar positive results. Even the Institute of Medicine agrees with the position that ARNPs practice efficaciously, increase access to care, are cost effective, and should practice at the top of their license and education (which supports team based or independent practice in some settings, that is primary care).

Below are some citations to support my position (just from a basic google search). I can find a wealth of more data (independent data) to support this. Now I invite you to prove me wrong with more extensive studies that are of better methodology than what I have provided without limitations (like you demand of me which is impossible). Doubt you'll find it but good luck.

1) Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses - PubMed - NCBI
2) Medscape: Medscape Access
3) http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality of Primary Care Advanced Practice Nurses.pdf
4) Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
5) https://www.hindawi.com/journals/nrp/2014/896587/

 

[deleted480308]

Yes actually the data shows this. Not only are ARNPs just as good as physicians in various outcomes of measure, but score even better. They have proven, time and time again to be cost effective and reduce cost of care. They have been studied extensively in countries beyond the U.S.A. and a vast majority of the data published proves their efficacy. ARNPs, CNMs, CNSs and CRNAs alike have been studied similarly and with similar positive results. Even the Institute of Medicine agrees with the position that ARNPs practice efficaciously, increase access to care, are cost effective, and should practice at the top of their license and education (which supports team based or independent practice in some settings, that is primary care).

Below are some citations to support my position (just from a basic google search). I can find a wealth of more data (independent data) to support this. Now I invite you to prove me wrong with more extensive studies that are of better methodology than what I have provided without limitations (like you demand of me which is impossible). Doubt you'll find it but good luck.

1) Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses - PubMed - NCBI
2) Medscape: Medscape Access
3) http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality of Primary Care Advanced Practice Nurses.pdf
4) Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
5) https://www.hindawi.com/journals/nrp/2014/896587/

Your first link is just a jumble of various opinion statements by groups....it appears to be a policy paper and not actual evidence of parity although it does mention one problem with many studies which is that they compare supervised nurses to physician as opposed to independent nurses

I'll look at the others when I'm not on my phone

 

[FNP_Blix]

Your first link is just a jumble of various opinion statements by groups....it appears to be a policy paper and not actual evidence of parity although it does mention one problem with many studies which is that they compare supervised nurses to physician as opposed to independent nurses

I'll look at the others when I'm not on my phone

Okay sure. Yea its just a brief but offers strong insights. Again, as I've asked you before, rebuttal with counter studies or evidence that shows NPs cannot practice safely.

 

[deleted480308]

#2 was a deadlink on my phone
#3 the only american source study (mundinger) used supervised nurses with a physician on call to give guidance

 

[deleted480308]

Okay sure. Yea its just a brief but offers strong insights. Again, as I've asked you before, rebuttal with counter studies or evidence that shows NPs cannot practice safely.

As I've said before (I believe to you) it woupd be unethical for anyone who thinks nps are inadequate for independent practice to set up that study. No one in good conscience would set up a study with the expectation that the new concept (independent nps) would hurt people when compared to the gold standard

For instance, I don't think a punch in the stomach is a good treatment for a small bowel obstruction. So I wouldn't set up a study to show that....it would be intentionally hurting people

 

[KGflyboy]

Yes actually the data shows this. Not only are ARNPs just as good as physicians in various outcomes of measure, but score even better. They have proven, time and time again to be cost effective and reduce cost of care. They have been studied extensively in countries beyond the U.S.A. and a vast majority of the data published proves their efficacy. ARNPs, CNMs, CNSs and CRNAs alike have been studied similarly and with similar positive results. Even the Institute of Medicine agrees with the position that ARNPs practice efficaciously, increase access to care, are cost effective, and should practice at the top of their license and education (which supports team based or independent practice in some settings, that is primary care).

Below are some citations to support my position (just from a basic google search). I can find a wealth of more data (independent data) to support this. Now I invite you to prove me wrong with more extensive studies that are of better methodology than what I have provided without limitations (like you demand of me which is impossible). Doubt you'll find it but good luck.

1) Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses - PubMed - NCBI
2) Medscape: Medscape Access
3) http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality of Primary Care Advanced Practice Nurses.pdf
4) Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
5) https://www.hindawi.com/journals/nrp/2014/896587/

I just read a few of these, and all they prove is that you formed incorrect conclusions from the data. I found one study mentioned that compared patients randomly assigned to either independent NPs or MDs. They concluded the outcomes were the same in various areas by surveying the patients six months later. The paper then specifically stated this is NOT adequate evidence the outcomes are the same due to their outcome measures being largely subjective. To cap it off, the authors mentioned half the patients in the study only saw the provider 0 or 1 times during the study. So we can conclude 1 thing here, if patients do NOT see a NP and also do NOT see an MD, the outcome is the same. Studies like this are a joke. Do you have any legit, randomized, blinded, prospective studies with objective outcomes? None of the links you posted meet that basic criteria.

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[deleted480308]

#5 was literally an analysis of how good the NP studies are and it said that less than half were at low risk of bias and that they routinely did an incomplete job of describing the qualifications of participant and details of how the study was actually done

You just provided a link that said the studies are not well done

 

[KGflyboy]

Okay sure. Yea its just a brief but offers strong insights. Again, as I've asked you before, rebuttal with counter studies or evidence that shows NPs cannot practice safely.

As mentioned by someone else, this type of study cannot safely be implemented in prospective, blinded, and randomized protocol without putting patients at risk. The studies you cite don't come anywhere close to proving what you want them to. The rebuttal evidence is based on the fact NPs have not had the training to recognize, evaluate, or treat the full scope of medical conditions physicians are trained to handle.

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[FNP_Blix]

Have NPs shown to be harmeful ever where society had to rethink their utilization? Is there a single study that shows that the NPs that are currently practicing independently are damaging to their patients? Can you prove any of this to warrent pulling NPs from practice who provide vital services to people who otherwise wouldnt have it? The answer is a big NO. You guys have no evidence to prove otherwise or you would have presented it already. Why does a medical institution, the IOM endorse NPs, and see what we are doing as a benefit to society? Can you answer these questions?

Also the studies you are asking for is not feasible. Many studies in medicine with imperfect methods or limitations still result in changes. You cant measure and compare the outcomes of every single disease process that we encounter and the outcomes we achieve. While the data is not perfect, it still proves a lot.

The conclusion I draw from my conversations with you is that you are scared and bitter that APNs as a whole are rising, and filling the void where you have not.

 

[FNP_Blix]

As mentioned by someone else, this type of study cannot safely be implemented in prospective, blinded, and randomized protocol without putting patients at risk. The studies you cite don't come anywhere close to proving what you want them to. The rebuttal evidence is based on the fact NPs have not had the training to recognize, evaluate, or treat the full scope of medical conditions physicians are trained to handle.

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Yea while physicians are "gold standard" NPs are and have been practicing independently and doing it safely, and effectively. For you to discredit this, you have to present data too. The burden of proof is on you.

 

[deleted480308]

Have NPs shown to be harmeful ever where society had to rethink their utilization? Is there a single study that shows that the NPs that are currently practicing independently are damaging to their patients? Can you prove any of this to warrent pulling NPs from practice who provide vital services to people who otherwise wouldnt have it? The answer is a big NO. You guys have no evidence to prove otherwise or you would have presented it already. Why does a medical institution, the IOM endorse NPs, and see what we are doing as a benefit to society? Can you answer these questions?

Also the studies you are asking for is not feasible. Many studies in medicine with imperfect methods or limitations still result in changes. You cant measure and compare the outcomes of every single disease process that we encounter and the outcomes we achieve. While the data is not perfect, it still proves a lot.

The conclusion I draw from my conversations with you is that you are scared and bitter that APNs as a whole are rising, and filling the void where you have not.

The IOM (old name) is a policy thinktank, not an association of practicing physicians

 

[KGflyboy]

Yea while physicians are "gold standard" NPs are and have been practicing independently and doing it safely, and effectively. For you to discredit this, you have to present data too. The burden of proof is on you.

You just acknowledged physicians are the gold standard. I agree. Therefore the burden of proof cannot rest on physicians to prove something else is less effective than the gold standard. That's not how science works. If I want to market a new treatment for headaches, I can't just walk in to the FDA and say, "I know Tylenol and NSAIDs are the gold standard, but you should approve my new treatment because the burden of proof should be on others to prove my new treatment is ineffective." The burden of proof is on whoever proposes the new treatment.

And you cannot say NPs have safely been practicing independently. The independent practice movement is relatively new. Time will tell.

 

[FNP_Blix]

You just acknowledged physicians are the gold standard. I agree. Therefore the burden of proof cannot rest on physicians to prove something else is less effective than the gold standard. That's not how science works. If I want to market a new treatment for headaches, I can't just walk in to the FDA and say, "I know Tylenol and NSAIDs are the gold standard, but you should approve my new treatment because the burden of proof should be on others to prove my new treatment is ineffective." The burden of proof is on whoever proposes the new treatment.

And you cannot say NPs have safely been practicing independently. The independent practice movement is relatively new. Time will tell.

Actually it does work that way. NPs continue to prove their competence and have data, despite what you choose to believe, to prove it. If you want to refute that, then prove it with evidence other than your opinion.

 

[deleted480308]

Actually it does work that way. NPs continue to prove their competence. If you want to refute that, then prove it with evidence other than your opinion.

what we are saying to you is that you have not proven parity.....those studies are no good.....

 

[FNP_Blix]

The IOM (old name) is a policy thinktank, not an association of practicing physicians

Okay thanks genius, you care answer the other questions I had in my reply?

 

[FNP_Blix]

what we are saying to you is that you have not proven parity.....those studies are no good.....

Clearly the studies out there do matter or we wouldnt be having this debate. As one of my friends (who's on a bill to be senator and who is in health policy) put it, "we need all hands on deck and this is basically a political argument." You want to go against that then and overturn the progress thats been made, then prove we are not competent.

 

[deleted480308]

Okay thanks genius, you care answer the other questions I had in my reply?

Have NPs shown to be harmful ever where society had to rethink their utilization?

They are by definition less trained and have to prove their parity for independent practice...not the other way around.

Is there a single study that shows that the NPs that are currently practicing independently are damaging to their patients?

I've already discussed why setting this up would be unethical

Can you prove any of this to warrent pulling NPs from practice who provide vital services to people who otherwise wouldnt have it?

I don't propose evaporating NPs. Just restricting them to supervised practice by a more qualified physician.

The answer is a big NO. You guys have no evidence to prove otherwise or you would have presented it already. Why does a medical institution, the IOM endorse NPs, and see what we are doing as a benefit to society?

This was answered above and the IOM isn't actually a "medical institution" in the way you imply

Can you answer these questions?

Just did

 

[deleted480308]

Clearly the studies out there do matter or we wouldnt be having this debate. As one of my friends (who's on a bill to be senator and who is in health policy) put it, "we need all hands on deck and this is basically a political argument." You want to go against that then and overturn the progress thats been made, then prove we are not competent.

I'm not arguing political expediency.....I'm arguing about who is better equipped to do the actual work. The opinion of a senator seeking votes means nothing to me

 

[FNP_Blix]

I'm not arguing political expediency.....I'm arguing about who is better equipped to do the actual work. The opinion of a senator seeking votes means nothing to me

Regardless if the studies did not matter, we would not be having this debate

 

[deleted480308]

Regardless if the studies did not matter, we would not be having this debate

that's not remotely true. Legislators don't give a crap about the quality of studies, they care about votes and appearances. Nursing unions are huge and popular.....the studies don't "matter" to them at all

You have to learn to separate the discussion. I'm not debating, "what did the legislature do" or even "what will they do". I'm discussing who is better equipped to do the work.

 

[FNP_Blix]

that's not remotely true. Legislators don't give a crap about the quality of studies, they care about votes and appearances. Nursing unions are huge and popular.....the studies don't "matter" to them at all

You have to learn to separate the discussion. I'm not debating, "what did the legislature do" or even "what will they do". I'm discussing who is better equipped to do the work.

Ah but we circle around again. There is an access issue and there aren't enough physicians to manage 320 million people. That is why we exist.

 

[deleted480308]

Ah but we circle around again. There is an access issue and there aren't enough physicians to manage 320 million people. That is why we exist.

Then the answer is more physicians and not letting people who are lesser trained pretend to be physicians. We wouldn't just let all the RNs go independent practice because we have a physician shortage. That would be silly. How about all the CNAs? That would put hundreds of thousands of more "providers" out there.....access for everyone!

 

[FNP_Blix]

Then the answer is more physicians and not letting people who are lesser trained pretend to be physicians. We wouldn't just let all the RNs go independent practice because we have a physician shortage. That would be silly. How about all the CNAs? That would put hundreds of thousands of more "providers" out there.....access for everyone!

Not the same buddy. NPs have been in practice for a long time, go through extensive schooling, and have their own credentialing process. So we are qualified to provide the services for which we've been educated. If you want to undo this, then physicians have to state why, using evidence as to why we are aren't qualified, and give evidence of how NPs are not safe. In the mean time, all hands on deck and lets get peope access to the healthcare they deserve and need. Sorry, but at this point we will have to agree to disagree.

 

[deleted480308]

Not the same buddy. NPs have been in practice for a long time, go through extensive schooling, and have their own credentialing process. So we are qualified to provide the services for which they've been educated. If you want to undo this, then physicians have to state why, using evidence, why we are aren't qualified, and give evidence of how NPs are not safe. In the mean time, all hands on deck. Sorry, but at this point we will have to agree to disagree.

The doterra saleslady down the street has had training too....she would need to produce some proof before I'll consider equal to physicians

 

[atomheart]

The future of any profession shouldn't hinge on studies and data. Exhibit A is the DO profession attempting to lengthen the separation from MD. Merely bringing up the studies sets off red flags. Much like Godwin's law, I have seen these conversations spiral downward from a debate into a discussion about study quality and the holy power of data to an unconvincable and unimpressed audience of physicians and student doctors. In general, the self-important attitude of militant NPs really deters the conversation more than anything else, and doesn't do much to convince beyond foster more distrust between professions.

 

[FNP_Blix]

The future of any profession shouldn't hinge on studies and data. Exhibit A is the DO profession attempting to lengthen the separation from MD. Merely bringing up the studies sets off red flags. Much like Godwin's law, I have seen these conversations spiral downward from a debate into a discussion about study quality and the holy power of data to an unconvincable and unimpressed audience of physicians and student doctors. In general, the self-important attitude of militant NPs really deters the conversation more than anything else, and doesn't do much to convince beyond foster more distrust between professions.

I agree. Lets not just look at the studies. Look at what NPs actually do and how they practice and that should be pretty convincing. Plenty of NPs I know that practice as good as physicians.

 

[Chibucks15]

I agree. Lets not just look at the studies. Look at what NPs actually do and how they practice and that should be pretty convincing. Plenty of NPs I know that practice as good as physicians.

And plenty are nowhere near


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[FNP_Blix]

And plenty are nowhere near


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Only as bad as the worst physicians 😉

 

[Chibucks15]

Oh stop it you cannot honestly believe the bad NPs are anywhere close to as competent as the worst physician. Purely on schooling and boards alone the knowledge base isn't there and that nonsense about being better to the patient is boloney too


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[atomheart]

I agree. Lets not just look at the studies. Look at what NPs actually do and how they practice and that should be pretty convincing. Plenty of NPs I know that practice as good as physicians.

I mean that's cool and all, but I'd like to hear it from a physician. I think they do a pretty good job in FM clinic, but I have noticed their training is much more piecemeal than physicians, and I can see them missing diagnoses or making poor clinical decisions because they don't have certain experiences.