Honestly I am on the fence about this. I was an Internist for a year before subspecializing in GI. So I get wanting to protect one's turf. If a DNP can do the basic job for less pay, there goes one's job security. However, I don't know if I buy the whole patient care argument in not allowing DNP to move in on primary care.
Procedural specialties (surgery, cards, GI, gyn, etc) take not just medical knowledge but time spent getting proficient in said procedures.
The type of consults I get from IM, FP, NP, or PAs sometimes show a lack of thought. IM/FP probably have more knowledge base and initiate better work ups. What I've seen is that if a patient is not routine they'll get a specialty consultation because a PCP just doesn't have the time nor the incentive to go over a patient's laundry list of problems. There's no reason a PCP should refer a patient with DM to an endocrinologist or a patient with IBS to a gastroenterologist. However, it happens regularly. Many PCP practices are mills where a patient has about 5-10 mins with the doc.
It doesn't take rocket science to follow the JNC-7 guidelines for preventative care. The caveat is that there occasionally comes a very complex patient who an astute and well trained PCP can either manage or properly refer for specialty care without having to get the shot-gun blast of unnecessary labs/imaging studies.
Midlevels should not be looked as a replacement for MDs but supplements. When the **** hits the fan, most patients would want to be seen by a medical doctor. In the rural parts of town, if MDs aren't willing to practice there, then midlevels are a viable option.
Okay if you think its okay for NPs to move in on primary care (I don't think it is okay BTW) then what about NPs doing GI?
For example:
Claudia Christensen is a nurse practitioner and she performs screening colonoscopies. "As far as I know, I am the only one doing them. It is not common at all," she says -- and she is right.
You see, Claudia Christensen, FNP, CGRN, nurse endoscopist and colorectal screening coordinator in the surgery services department of the Alaska Native Medical Center, has in fact performed more than 1,200 screening colonoscopies over the past three years; prior to which she (also for three years) performed flexible sigmoidoscopies.
After the training she received from the general surgeons at her facility and the hands-on training she received at the National Procedures Institute, Christensen did not undergo any further schooling or instrumentation. She did, however, have to complete 50 unsupervised colonoscopies before she could be credentialed to fly solo.
Currently, she performs the colonoscopies alone, but with a physician available within the hospital. On the average case, to assist her, she has a nurse who administers conscious sedation and an assistant or tech in the room during the procedure.
"There certainly is a licensing issue; I think there probably is a philosophical issue right now as well. Although I do think as the changing landscape of GI continues to evolve, that phenomenon may occur. It's already clearly occurred in the practice, where mid-levels are used as physician extenders for the up-front evaluation as to whether or not a patient needs the procedure done.
"Clearly, the role of the GI proceduralist physician will continue to evolve over time and it certainly wouldn't be unforeseen that mid-level providers may at some point be used in an ambulatory surgery center (ASC) to do routine cases. That's clearly not the norm today, but as they continue to have reimbursement pressures and a variety of other factors impacting the GI physicians, there will be multiple pathways they will pursue to continue to evolve with the market," Poisson concludes.
Christensen says that the evolution of her involvement into the realm of performing screening colonoscopies began as a reaction to the increased findings of polyps and the influx of referrals for so many people to get the whole exam (colonoscopy as well as the flexible sigmoidoscopies). "The surgeons asked if I would just go ahead and train to do colonoscopies and that's how that happened," she explains.
One of the reasons why the program is so successful in Alaska is because nurse practitioners have prescriptive authority "and so it is within our scope of practice to do them," Christensen says.
Currently, the medical center Christensen works at serves the entire state of Alaska. The state, she says, has a high rate of colorectal cancer -- "about twice that of any other ethnic group in the world," she notes. She says the overall screening rate for the state has typically remained very poor and cites its landscape of primarily small and very rural areas as the reason for this. Of course, this couples with the fact that the Alaskan system has no actual GI docs and only general surgeons.
So, Christensen herself performs nearly 600 colonoscopies a year - and this is in addition to the ones the surgeons do. "We're doing better with screening rates," she says cheerfully, adding that the facility still operates a flex-sig program done by nurses in the primary care clinic.
In Christensen's Anchorage system, the screening rates have increased from 15 percent to 50 percent in the three years since she and her colleagues first implemented the program -- and 20 percent of that increase can be directly applied to her newfound capability.
"We were able to really increase screening rates here," she affirms. "We've made a big impact in this area." She explains that she also travels to other regional hospitals throughout the state and performs the colonoscopies "independently, without a physician on-site."
"I think this needs to be published because this is a safe, effective, extremely cost-effective alternative to physician providers. I think some people in the GI community would agree that to really get a handle on the backlog for the underinsured and uninsured, that this is really an excellent thing to do."
She continues, "The quality needs to be maintained. I think our system is an ideal setting to do it, and we have general surgeons available at all times."
Her advice? "Find a supportive group of physicians. They are out there; people that are willing to admit that our being in the system is helping to increase screening and not really decreasing their bottom line or business at all. Actually, it is probably helping to find more - more polyps, more cancers, etc."
Christensen says that in order to move down this path in the rest of the United States, nurses must take action to ensure that their state nursing boards make the scope of practice for mid-levels broad enough that they can do this type of procedure. "There are many states in which this is far from happening because this is not within the scope of practice yet for a mid-level provider, to prescribe or give sedation or do these kinds of things to begin with. In many states, this is the beginning stumbling block," Christensen explains.
Varying levels of nurse-led programs have shown high successes rates. Australia established the practice of nurse practitioner- led colorectal screenings, according to a journal article in the 2005 January/February issue of Gastroenterology Nursing.1
In response to the staggering colorectal cancer rates in the southern Australian area, a teaching hospital launched this nurse practitioner-led colorectal screening service. The service provided fecal occult blood testing and flexible sigmoidoscopy, and was accompanied with health education and patient counseling, as well as referrals. Establishment of this clinic required "advanced and extended theoretical and clinical preparation for the nurse practitioner, as well as development of interdisciplinary relationships, referral processes, clinical infrastructure, and a marketing strategy," the article reads.
According to an internal audit of the first 100 flexible sigmoidoscopy patients in the program, the service revealed outcomes that compared favorably with other colorectal screening services, "as well as a high level of patient satisfaction," the researchers wrote. It is also interesting to note in this case that flexible sigmoidoscopy had not been a commonly used screening tool in Australia due to the lack of resources.
Over the last three years that Christensen has performed screening colonoscopies, she has found 13 cancers. "And those, you know, were cancers that would have been found late," she points out.
As for adverse events, "I have had some," she admits, "but not above the average for that procedure. I have had one bleed, two perforations
no anesthesia problems, no other adverse events at all."
She further explains that all of those patients did well. For example, in one of the perforations, Christensen says the area sealed itself off and the patient didn't have to have anything done. The other was actually caused by air in the small bowel and it had an obstruction. "Nothing over the average for that procedure," she notes.
"I think that what this is really all about is prevention," Christensen says. "It's not about diagnosing. It's not about doing something that isn't within the realm of prevention and screening, and I think patients and physicians need to know that what my job is as a nurse practitioner is not to be a 'mini doctor' or an extension of them, but to identify or prevent a disease that is absolutely preventable before it starts.
"It's screening. It's not diagnostic, and with the proper training and education and experience, especially experience doing these types of things; it is a very, very doable and valuable addition to our healthcare system."
http://www.endonurse.com/cms/welcom...tp://www.endonurse.com/articles/6c1feat3.html
