Nurses Run the Show

[secretwave101]

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I've been tooling around the website of my State legislature after petitioning my U.S. Reps in favor of the Baucus bill. Out of curiosity, I looked up the Health Care Committee. Guess what the largest representing profession was in the group? Nurses. And a chiropractor. There were some business people and a teacher or two. And one doc who retired in 1992. But nurses were the predominant group, including the committee chair.

I have no problem with nurses or chiropractors being involved in politics and representing the populace. But if American health policy is largely determined by allied health professionals, we're going to see an environment that is increasingly good for them and not necessarily good for doctors.

How can they understand the litigation crisis when they've never REALLY dealt with OB responsibilities, for example? How can they actually understand the influence of insurance and billing and chronic narcotic seekers unless they've provided care in this environment? One of the latest rants in our forum is about nurses thinking they can act like primary care doctors (DNP's). With nurses effectively running the health care committees (in my state of WA at least), do you really expect primary care overhaul in this country to be centered around FP's?

The AAFP is begging anyone interested in politics to get involved. I can see why. If health care reform is being largely driven by nurses and other non-medical people, doctors everywhere are likely to regret it.

My question, thus, is do you agree? If so, does anyone have experience with political involvement?

 

[Faebinder]

Forgive me my ignorance.... but what sort of influence does the "Health Care Committee" have? Can you elaborate for us none-political science crazies. (Man I regret my undergrad/grad being in engineering and not business or political science or straight up easy fine arts major).

 

[sophiejane]

I will just reiterate what I've said before ,I know they are a big lobby and are moving fast getting more and more independence, but I do believe the problem of nurses having too much responsibility and too little supervision is unfortunately going to take care of itself in the form of litigation and rising malpractice for them.

There is no shortcut to having the responsibility a physician has, or the scope of practice. It must be done the old fashioned way, and when it's not, when there are corners cut, well, stay tuned, folks...

 

[secretwave101]

I don't know much about this stuff either. I've been dismayed to realize that knowledge of medicine is only a small part of what doctors need to know. Legal, business, billing and political stuff all are necessary too.

But here's my general understanding of committees:

Any legislator who gets a burr in his/her rear can propose a law (at that point called a "bill"). The first stop for the bill to become a law, is with the committee that oversees bills in that category - so health care bills go to the health care committee.

This committee gets to decide if the bill has any merit at all. They're supposed to hold public hearings about the bill and take that commentary into account. The chairNURSE totally controls the meeting, and from what I've heard, there is a lot of power in this position. If the chair doesn't like a bill, there are tricky ways to make it tougher for the bill to really get the attention it deserves.

After hearings etc, if the committee supports the bill, it goes before the legislature (either house or senate) for debate. If the committee doesn't like it, I'm pretty sure it dies.

You've heard the phrase, "Died in committee"? It's in reference to the fact that many bills never see debate because the committee killed it.

 

[secretwave101]

I do believe the problem of nurses having too much responsibility and too little supervision is unfortunately going to take care of itself in the form of litigation and rising malpractice for them.

Totally agree with you, SJ on the DNP front. But this is just one part of the picture. The laws being passed deal with insurance, litigation and probably most importantly right now, medicare payouts. Do we want all these decisions being made by nurses and chiropractors?

 

[All4MyDaughter]

But here's my general understanding of committees:

Any legislator who gets a burr in his/her rear can propose a law (at that point called a "bill"). The first stop for the bill to become a law, is with the committee that oversees bills in that category - so health care bills go to the health care committee.

This committee gets to decide if the bill has any merit at all. They're supposed to hold public hearings about the bill and take that commentary into account. The chairNURSE totally controls the meeting, and from what I've heard, there is a lot of power in this position. If the chair doesn't like a bill, there are tricky ways to make it tougher for the bill to really get the attention it deserves.

After hearings etc, if the committee supports the bill, it goes before the legislature (either house or senate) for debate. If the committee doesn't like it, I'm pretty sure it dies.

You've heard the phrase, "Died in committee"? It's in reference to the fact that many bills never see debate because the committee killed it.

Wait - those committees are generally made of up of elected legislators. Are you saying that the legislators who run this committee are mostly nurses who have been elected to public office? It seems strange (not that it couldn't happen) that there would be so many nurses or other health professionals in your state legislature. Only because I think health professionals run for public office at a lower rate than say, attorneys or businessmen.

And assuming your state legislature has two houses (most do - House of Representatives and Senate) then there would be two committees (typically). Which one are you referring to?

My state Senate's "Health and Welfare" committee has a dental hygienist, a former nursing home administrator and a registered pharmacist on it. Then there is a retired teacher, a farmer, several attorneys and a number of businessmen on it. I don't think there is a physician in the state Senate here - so there is no way that one could possibly be on the committee. It may be the same thing in your state. It doesn't mean anything nefarious is going on.

Kentucky Senate Health & Welfare Committee

The Kentucky House House Health and Welfare Committee has two physicians (retired), a nurse, a chiropractor and a hospital administrator on it, plus the usual assortment of attorneys and businessmen. Kentucky House Health & Welfare Committee

The Lt. Governor of Kentucky is a physician: Daniel Mongiardo I don't think that makes much of a difference to physicians in this state though. Dr. Mongiardo has the entire state to worry about, as he is the elected representative of all Kentuckians, not just physicians.

I would say physicians run for political office at a much lower rate than other professions. For one, they probably don't have time to be legislators while they are in practice. And the salary of a state lawmaker is certainly much less than they could earn working as a physician.

Remember, these folks are first and foremost loyal to the districts that elected them. Not to their profession or their church or their mother-in-law. If they aren't they won't be in office very long. So the use of "ChairNURSE" to describe the person who leads the committee you are referring to is probably inaccurate. If they have amassed enough seniority and the confidence of their peers to rise to the rank of committee chair in a state legislature, I assure you they've been busy with more legislative tasks than just pushing a "nursing agenda."

Most of the law that REALLY affects the practice of Medicine, Pharmacy, Dentistry, Nursing, etc in any given state is administrative law anyway. And that is made by the governing board of the respective profession, not the legislature.

Also, there are ways that bills stalled in committee (for whatever reason) can be brought to the floor of the House or Senate. See also, Legally Blond II. That practice is going to vary from state to state in terms of procedure, number of votes required, etc.

Yes, I got my BA in Political Science. 🙂

 

[All4MyDaughter]

Totally agree with you, SJ on the DNP front. But this is just one part of the picture. The laws being passed deal with insurance, litigation and probably most importantly right now, medicare payouts. Do we want all these decisions being made by nurses and chiropractors?

This is sort of inflammatory and inaccurate.

For one thing, lawmakers are called upon to make laws about all sorts of things that they do not have personal experience in. We have legalized gambling (horseracing) in this state. Our legislators (all of them: the nurses and the preachers and the farmers and the real estate agents) vote on gambling (and ALL other) laws, even though they aren't employed in that industry. That's just how representative democracy works.

So, health care decisions aren't solely being made by "nurses and chiropractors." They are made by elected legislators who are beholden, first and foremost to their constituents. You could consider a push to get more physicians in elected government, I suppose, but I doubt it would improve things tremendously. Mainly because to GET elected and STAY elected they would become a politician first and a physician second. No one pushing the agenda of their personal profession and ignoring the will of their consituents is going to be very effective and longstanding in their office.

The other thing your model negates is the impact of lobbying. I think this has a FAR more detrimental effect on health policy and law than having "nurses and chiropractors" in governmental roles. The corporate interests with the deepest pockets have the resources to greatly impact the passage of laws at both the federal and state levels. This means HMOs, drug companies, insurance companies, etc. That Golden Rule (he who has the gold makes the rules) is a much bigger problem, IMO.

 

[Leukocyte]

I do believe the problem of nurses having too much responsibility and too little supervision is unfortunately going to take care of itself in the form of litigation and rising malpractice for them.

I have to disagree. You are under-estimating these DNPs. These DNP's are not stupid. They will treat the bread and butter stuff, and refer the other stuff to specialists who will be more than happy to get a good flow of consult requests. A FM doctor does not refer to specialists unless he really has to. But these DNPs are SMART. They are in it for the "bread and butter", not the zebras. They will be refering to specialists like crazy, and the specialists will be MORE THAN HAPPY to take their many "easy" consults to make a quick buck.

The issue with DNPs is that they are STEALING the BREAD AND BUTTER cases (which make up the MAJORITY of our daily workload and livelihood) from the FM doc's mouth. Yes FM docs are more knowledgable than a DNP. We all know that. Even the smart DNPs know that. The issue here is the BREAD AND BUTTER cases. They are after that. If they take that from us, then there goes 60-70% of our income.

This is not about who is more knowledgable. It is about MONEY. Basicly the DNP's are trained to:

-be proficient in treating bread and butter cases.
-know when to refer tp specialists(when encountered with a case that is not bread and butter)

and that is why DNPs are so dangerous to the FM doc....They will steal our bread and butter cases while continue to operate by refering everything else to specialists who will be more than happy to make a quick buck out of the DNPs "easy" consults.

So NO, the problem will NOT take care of its own. We need to do something about it NOW.

 

[Red Beard]

I second leukocytes post, and add that the gradual decline in scope of practice, due to financial and time pressures now, and in the near future to lack of available training, may leave family physicians few practice options but to manage teams of midlevels and coordinate referrals. Perhaps that could be a viable and profitable role, but how many of us studied medicine to become paper pushing managers?

 

[deleted87716]

I hear what you're saying, and the scope-of-practice issues raised by the DNP lobbyists deserves our attention. However...

As long as there are patients with multiple medical problems who want and appreciate a single doctor who can take care of them as a whole person rather than a bunch of organ systems, good family physicians will continue to have job security into the indefinite future.

As the saying goes, if you're really worried about being replaced by a mid-level, maybe you should be.

 

[Leukocyte]

I As long as there are patients with multiple medical problems who want and appreciate a single doctor who can take care of them as a whole person rather than a bunch of organ systems, good family physicians will continue to have job security into the indefinite future.
.

That is what I am saying. The FM docs will be left to deal with the complicated "patients with multiple medical problems". That is nice and dandy from an efficiency point of veiw, but it does not put enough food on the table. We need the "easy" sore throats, HTN F/Us, prenatal visits, and WCCs to put food on the table. We need those MANY easy clinic visits....and that is what DNPs want to take from us, the easy cases...NOT the few complicated cases.

 

[deleted87716]

That is what I am saying. The FM docs will be left to deal with the complicated "patients with multiple medical problems". That is nice and dandy from an efficiency point of veiw, but it does not put enough food on the table. We need the "easy" sore throats, HTN F/Us, prenatal visits, and WCCs to put food on the table. We need those MANY easy clinic visits....and that is what DNPs want to take from us, the easy cases...NOT the few complicated cases.

Well, all of us are different, I suppose. I can see a 99214 almost as fast as I can a 99213. I'd rather see more 99214's.

And there aren't just a "few" complicated patients. There are tons of 'em, and more every day.

 

[secretwave101]

This is sort of inflammatory and inaccurate.

Wasn't intended to be inflammatory. I don't think they are incompetent or unqualified to be there. I just think that as new bills appear, physicians' voices should be a part of the discussion. I do not believe that decisions that highly affect the livelihoods of physicians should be made by allied health professionals who were initially trained to take care of their own (we all are). I'll assume that all are stand-up, honest people and aren't out to further their professions, per se, but they just can't know what it's like to be a doctor in America unless they've been one.

The other thing your model negates is the impact of lobbying. I think this has a FAR more detrimental effect on health policy and law than having "nurses and chiropractors" in governmental roles.

I have to agree with you on that one. But I stand by my assertion that physicians need to be involved with the political process because even well-meaning people can make decisions that will steam-roll docs if they don't have a voice.

And yes, each of these people are fully elected by the populace. This tells me that docs shouldn't flat-out regard themselves as "too busy" to participate. They may not be able to function as elected officials, but political ignorance is professional suicide.

 

[Taurus]

I have to disagree. You are under-estimating these DNPs. These DNP's are not stupid. They will treat the bread and butter stuff, and refer the other stuff to specialists who will be more than happy to get a good flow of consult requests. A FM doctor does not refer to specialists unless he really has to. But these DNPs are SMART. They are in it for the "bread and butter", not the zebras. They will be refering to specialists like crazy, and the specialists will be MORE THAN HAPPY to take their many "easy" consults to make a quick buck.

The issue with DNPs is that they are STEALING the BREAD AND BUTTER cases (which make up the MAJORITY of our daily workload and livelihood) from the FM doc's mouth. Yes FM docs are more knowledgable than a DNP. We all know that. Even the smart DNPs know that. The issue here is the BREAD AND BUTTER cases. They are after that. If they take that from us, then there goes 60-70% of our income.

This is not about who is more knowledgable. It is about MONEY. Basicly the DNP's are trained to:

-be proficient in treating bread and butter cases.
-know when to refer tp specialists(when encountered with a case that is not bread and butter)

and that is why DNPs are so dangerous to the FM doc....They will steal our bread and butter cases while continue to operate by refering everything else to specialists who will be more than happy to make a quick buck out of the DNPs "easy" consults.

So NO, the problem will NOT take care of its own. We need to do something about it NOW.

👍

 

[All4MyDaughter]

Wasn't intended to be inflammatory. I don't think they are incompetent or unqualified to be there. I just think that as new bills appear, physicians' voices should be a part of the discussion. I do not believe that decisions that highly affect the livelihoods of physicians should be made by allied health professionals who were initially trained to take care of their own (we all are). I'll assume that all are stand-up, honest people and aren't out to further their professions, per se, but they just can't know what it's like to be a doctor in America unless they've been one.

I'm not sure what you are advocating that would work within the context of our country's political system. Especially the part about not allowing "allied health professionals" to make decisions that affect the livelihood of physicians. Show me a state where those decisions are SOLELY made by "allied health professionals" - I doubt very seriously that one exists. If a nurse or a dental hygienist is duly elected he or she has the same right to vote on every piece of legislation as the duly elected realtor, farmer or teacher does.

I'm betting that the makeup of legislative health committees in the other 49 states mirrors those in Kentucky: some physicians, some nurses, some other health professionals and a healthy serving of NON health professionals. It's just not practical to think that major legislative initiatives affecting physicians are ONLY going to be handled by physicians. No other profession has that luxery.

I'd be interested to see a breakdown of the professions represented in state legislatures and in Congress. I'm sure attorneys are #1 but I'm guessing the physicians (mostly retired is my bet) are as evenly represented as nurses, dentists, pharmacists and other health professionals. Or at least that the proportion of those professionals in legislative positions is consistent with the number of those professionals amongst the general population. I'm sure there is a survey out there.

Getting an additional physician or two elected to state legislatures or to Congress is not the answer and is unlikely to make a significant difference in any of your areas of concern. Unified, focused lobbying efforts by physician organizations and public education on key points of interest to physicians is probably the answer. Individual physicians can become involved by donating money to professional and other organizations that lobby Congress and by writing to their own representatives. And voting.

 

[sophiejane]

The point is, not all that looks like bread and butter is in fact bread and butter. If you don't know to look for the zebras, you will never find them in the herd of horses.

(Is that enough analogy for you?! 😉 )

I still contend that they will harm people by mistaking something gravely dangerous for something common and benign,simply because they don't have a wide enough differential or enough experience treating badness to know better. In those cases, unfortunately, by the time the specialist sees them it might be too late.

 

[deleted87716]

The point is, not all that looks like bread and butter is in fact bread and butter. If you don't know to look for the zebras, you will never find them in the herd of horses.

(Is that enough analogy for you?! 😉 )

I still contend that they will harm people by mistaking something gravely dangerous for something common and benign,simply because they don't have a wide enough differential or enough experience treating badness to know better. In those cases, unfortunately, by the time the specialist sees them it might be too late.

As an example:

SORE THROAT, SYSTEMIC CAUSES

Let us begin with VINDICATE.

V—Vascular reminds one of blood dyscrasias such as leukemia, agranulocytosis of numerous causes, and Hodgkin disease.

I—Inflammatory diseases include the most common causes of sore throat, streptococcal or viral pharyngitis, but one must also consider the less frequent infectious diseases here. Beginning with the smallest organism and moving to the largest, one thinks of viral pharyngitis, particularly herpangina (due to Coxsackie virus), pharyngoconjunctival fever (due to eight or more viruses), and infectious mononucleosis. Viral influenza may begin with a sore throat. Moving to a larger organism, one should remember that Eaton agent (Mycoplasma) pneumonia might be associated with pharyngitis.

Next, bacterial causes such as group A hemolytic Streptococcus (with or without scarlet fever), diphtheria, Listeria monocytogenes, and meningococcemia should be considered. Gonorrhea is increasingly a cause of sore throat. Tuberculosis should also be mentioned, although it is rare in contemporary affluent societies. Consider among bacterial causes sinusitis, tonsillar or peritonsillar abscess (quinsy), and retropharyngeal abscess: Staphylococcus organisms may cause these but they rarely cause the common sore throat.

Moving to the next largest organisms, the spirochetes, think of syphilis and Vincent angina. Finally, remember the fungi, including thrush (moniliasis) and actinomycosis.

N—Neoplasm and carcinomas may include Hodgkin disease and leukemia. The Schmincke tumor is of particular interest here.

D—Degenerative diseases are an unlikely cause of sore throat, just as they are unlikely to cause pain anywhere.

I—Intoxication brings to mind chronic alcoholism and smoker's throat. Agranulocytosis may also be included in this category, because it is so often drug-induced.

C—Congenital diseases are an infrequent cause of sore throat, but a hiatal hernia with reflux esophagitis may cause recurrent sore throat, because there may be reflux of gastric juice all the way to the posterior pharynx in the recumbent position. An elongated uvula may also be responsible.

A—Allergic diseases include angioneurotic edema of the pharynx or uvula and allergic rhinitis, otherwise, this category is a rare cause of sore throat.

T—Trauma brings to mind foreign bodies such as chicken bones and tonsilloliths.

E—Endocrine causes of sore throat should remind one of subacute thyroiditis; although the pain is really in the neck, the patient will report a "sore throat."

 

[All4MyDaughter]

As an example:

SORE THROAT, SYSTEMIC CAUSES

Let us begin with VINDICATE.

V—Vascular reminds one of blood dyscrasias such as leukemia, agranulocytosis of numerous causes, and Hodgkin disease.
...snip...

I love it when you talk nerdy. 😉

 

[deleted87716]

I love it when you talk nerdy. 😉

Been there, done that, got the t-shirt. 😉

<--- Would make a great avatar.

 

[secretwave101]

I'm not sure what you are advocating that would work within the context of our country's political system. Especially the part about not allowing "allied health professionals" to make decisions that affect the livelihood of physicians. Show me a state where those decisions are SOLELY made by "allied health professionals" - I doubt very seriously that one exists. If a nurse or a dental hygienist is duly elected he or she has the same right to vote on every piece of legislation as the duly elected realtor, farmer or teacher does.

I'm betting that the makeup of legislative health committees in the other 49 states mirrors those in Kentucky: some physicians, some nurses, some other health professionals and a healthy serving of NON health professionals. It's just not practical to think that major legislative initiatives affecting physicians are ONLY going to be handled by physicians. No other profession has that luxery.

I'd be interested to see a breakdown of the professions represented in state legislatures and in Congress. I'm sure attorneys are #1 but I'm guessing the physicians (mostly retired is my bet) are as evenly represented as nurses, dentists, pharmacists and other health professionals. Or at least that the proportion of those professionals in legislative positions is consistent with the number of those professionals amongst the general population. I'm sure there is a survey out there.

Getting an additional physician or two elected to state legislatures or to Congress is not the answer and is unlikely to make a significant difference in any of your areas of concern. Unified, focused lobbying efforts by physician organizations and public education on key points of interest to physicians is probably the answer. Individual physicians can become involved by donating money to professional and other organizations that lobby Congress and by writing to their own representatives. And voting.

I'm saying nothing more than that nurses and chiropractors (at least here) are gaining positions of political power - which, for many reasons, is good for their professions - and family doctors should strive to also. The AAFP agrees with this position; I'm not reinventing the wheel here. Also, while I can agree that lobbying has real influence, I reject your notion that real power lies exclusively with lobbyists and that running for office is superfluous to real change.

The mission statement of every single member on the health care committee states some version of how they want "to improve health care" (clearly THEY believe they can do something irrespective of lobbyist influence). In my opinion, family doctors should be part of that process wherever possible.

 

[All4MyDaughter]

I'm saying nothing more than that nurses and chiropractors (at least here) are gaining positions of political power - which, for many reasons, is good for their professions - and family doctors should strive to also. The AAFP agrees with this position; I'm not reinventing the wheel here. Also, while I can agree that lobbying has real influence, I reject your notion that real power lies exclusively with lobbyists and that running for office is superfluous to real change.

The mission statement of every single member on the health care committee states some version of how they want "to improve health care" (clearly THEY believe they can do something irrespective of lobbyist influence). In my opinion, family doctors should be part of that process wherever possible.

Running for office isn't superfluous, it's just a hard, hard way to effect change. Our government system is not designed to allow one person to make an enormous impact, especially not at first. But more power to those who are willing to try.

 

[MedicineDoc]

I hear what you're saying, and the scope-of-practice issues raised by the DNP lobbyists deserves our attention. However...

As long as there are patients with multiple medical problems who want and appreciate a single doctor who can take care of them as a whole person rather than a bunch of organ systems, good family physicians will continue to have job security into the indefinite future.

As the saying goes, if you're really worried about being replaced by a mid-level, maybe you should be.

I disagree. I have heard a bunch of different versions of why we shouldn't worry about a bunch of poorly trained midlevels taking over primary care. To me they all sound like different versions of a lullaby to help people sleep without grinding their teeth at night. It is the established physicians that are selling out the profession. Your version sounds a little like you might be making some money off of these midlevels (for the time being that is).

 

[deleted87716]

Your version sounds a little like you might be making some money off of these midlevels (for the time being that is).

Nope. I don't work with mid-levels.

It is the established physicians that are selling out the profession.

How's that, exactly?

 

[sophiejane]

See, when I think of myself as a "gatekeeper", I think as much about being a portal to specialists (when appropriate) as I do keeping that portal closed because my goal is to prevent them from getting bad enough to need a referral.

Ultimately, a nurse who knee-jerk refers on a daily basis for things like sprained ankles and reflux, but thinks he or she is competent to treat a "sore throat" in a smoker may do so several times in the course of year with antibiotics, forgetting to ask about dysphagia (and they don't always offer such useful information, even when it is pretty significant), meanwhile throat cancer is marching along through the lymph nodes and the rest of the body.

Look, we have seen what happens when people take short cuts--bridges collapse, buildings collapse, things get missed and people die.

A nurse playing doctor at ANY level, no matter how much extra nursing training he or she gets, is a short cut, and they are playing with fire.

 

[MedicineDoc]

How's that, exactly?

I would point to the Flexner report of 1910. Basically what we have is a regression to the pre Flexner report days through Nursing Board awarded degrees which can even be obtained online such as nurse "practitioner" and the "Doctorate in nursing" (which a complete sham as it adheres to no PhD standards ever set forth and utilizing the title Doctorate as a marketing ploy).

"A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired" The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word "quack" flourished. There is no evidence that the mass of Americans were dissatisfied with this situation.."

The Flexner report not only caused a tremendous increase in the quality of medical education but also the cost and time spent receiving a medical education. By hiring what are being sold as "physician equivalents" created through circumventing the standards set forth by the Flexner report by utilizing the Nursing boards physicians are basically selling out the profession as well as the quality of the Americal medical system as a whole.

 

[leviathan]

I heard about a case of a 24 y/o guy who was feeling ill for almost 4 months, and visited his family doctor many times in that period of time. At the 4th month he developed a joint pain and fever, and shortness of breath. The family doc sent him home with a week's worth of antibiotics and a referral to a rheumatologist. Within a few days he had collpased from a ruptured mitral valve due to a severe staph infection. After surgery he had an embolic stroke and later began to hemorrhage, and died about a week later.

If FPs can make mistakes like these, what will happen when DNPs start becoming primary caregivers for patients? They can deal with the bread and butter cases, but can miss telltale warning signs (eg. joint pain + fever).

 

[MedicineDoc]

Retrieved from "http://en.wikipedia.org/wiki/Flexner_Report"
Flexner Report

 

[deleted87716]

Honestly, throwing the Flexner report up as a defense is almost as histrionic as anything Mundinger has written. Apples & oranges.

Keep in mind that I'm on your side here, but seriously...we can do better than that.

 

[MedicineDoc]

Honestly, throwing the Flexner report up as a defense is almost as histrionic as anything Mundinger has written. Apples & oranges.

Keep in mind that I'm on your side here, but seriously...we can do better than that.

I'm not a histrionic type of guy. How is it different? They are being marketed as the new primary care. There are top medical journals with statements with words to the effect of it remains to be seen whether primary care will be completely taken over by nurse practitioners and the like.

 

[jetproppilot]

I will just reiterate what I've said before ,I know they are a big lobby and are moving fast getting more and more independence, but I do believe the problem of nurses having too much responsibility and too little supervision is unfortunately going to take care of itself in the form of litigation and rising malpractice for them.

There is no shortcut to having the responsibility a physician has, or the scope of practice. It must be done the old fashioned way, and when it's not, when there are corners cut, well, stay tuned, folks...

I agree with you.

But it won't deter the infiltration of paraprofessionals.

My mom, a high-school cafeteria worker, recently cut a finger on the job.

Required sutures.

She was sent to a clinic.

Never saw a doctor.

A DNP saw her, assessed her, and sutured her thumb.

 

[racerx]

Jet,

I'd be interested to hear how it's any different than the CRNA's pushing for independent practice.

Once they start pushing for DRNA (or whatever they'd present as a "terminal degree") and independent practice using DNP models, medicare/medicaid, and private insurers will, as 'the dollar matters', only reimburse at lower rates. If they can pay an independent DRNA to provide anesthesia for half the price of an MD, that's all they'll pay any anesthesia provider.

 

[jetproppilot]

Jet,

I'd be interested to hear how it's any different than the CRNA's pushing for independent practice.

Once they start pushing for DRNA (or whatever they'd present as a "terminal degree") and independent practice using DNP models, medicare/medicaid, and private insurers will, as 'the dollar matters', only reimburse at lower rates. If they can pay an independent DRNA to provide anesthesia for half the price of an MDA, that's all they'll pay any anesthesia provider.

I didnt say it was different.

Sad in all specialties with midlevel encroachment.

Especially if the nurse is calling himself/herself "Doctor".

BTW, whats an MDA?

 

[deleted87716]

Currently, 23 states allow NPs to practice independently, without physician supervision. This doesn't have anything to do with the DNP.

Link: http://www.acnpweb.org/i4a/pages/index.cfm?pageid=3465

 

[racerx]

BTW, whats an MDA?

My lazy, it's 1:00 AM, abbreviation for MD Anesthesiologist. Yes, I'm fully aware that DO Anesthesiologists are in the trenches too. It was late and I was tired, lazy, and typing after 2 Glenfiddich's on the rocks.

I'm going to go ahead and assume I've been properly chided so we can move on with the productive part of the discussion. . . if indeed there was a productive part.

Update: Apparently there are other lazy, corner-cutting neophytes too.
http://www.ridgeviewmedical.org/providers/ProviderDefinitions.aspx

And, from an SDN anesthesiology forum regular attending, as found on a *gasp* CRNA website:

Re: Questions for MilitaryMD (anesthesiologist)

Quote:
Originally Posted by MmacFN
Ill start!

Hi Mil, Welcome to the forum!

I have been reading the anesthesiology forum on SDN for sometime now and i have noticed that many of the physicians there feel the term "MDA" is [SIZE=-1]derogatory. However, in daily practice many of us have heard and seen this used without any offence meant or being taken.[/SIZE]

[SIZE=-1]Is this offensive? Why is it? and how do you feel about it?[/SIZE]



"offense" like "beauty" is in the eye of the beholder.....I don't find it offensive....but then again....I find that I can learn things from experiened non-physician providers.........whereas many of the ones who take offense at MDA think their training teaches them everything they need to know...

short answer....I don't know why it is offensive."

 

[sophiejane]

I agree with you.

But it won't deter the infiltration of paraprofessionals.

My mom, a high-school cafeteria worker, recently cut a finger on the job.

Required sutures.

She was sent to a clinic.

Never saw a doctor.

A DNP saw her, assessed her, and sutured her thumb.

That is a perfectly reasonable use of a DNP. What is not perfectly reasonable is for them to set up a solo practice in a little town pretend they are the local doctor.

 

[racerx]

Sad in all specialties with midlevel encroachment.

Especially if the nurse is calling himself/herself "Doctor".

What's sad is that some patients are going to suffer poor outcomes before this changes.

 

[MacGyver]

I have to disagree. You are under-estimating these DNPs. These DNP's are not stupid. They will treat the bread and butter stuff, and refer the other stuff to specialists who will be more than happy to get a good flow of consult requests. A FM doctor does not refer to specialists unless he really has to. But these DNPs are SMART. They are in it for the "bread and butter", not the zebras. They will be refering to specialists like crazy, and the specialists will be MORE THAN HAPPY to take their many "easy" consults to make a quick buck.

The issue with DNPs is that they are STEALING the BREAD AND BUTTER cases (which make up the MAJORITY of our daily workload and livelihood) from the FM doc's mouth. Yes FM docs are more knowledgable than a DNP. We all know that. Even the smart DNPs know that. The issue here is the BREAD AND BUTTER cases. They are after that. If they take that from us, then there goes 60-70% of our income.

This is not about who is more knowledgable. It is about MONEY. Basicly the DNP's are trained to:

-be proficient in treating bread and butter cases.
-know when to refer tp specialists(when encountered with a case that is not bread and butter)

and that is why DNPs are so dangerous to the FM doc....They will steal our bread and butter cases while continue to operate by refering everything else to specialists who will be more than happy to make a quick buck out of the DNPs "easy" consults.

So NO, the problem will NOT take care of its own. We need to do something about it NOW.

I agree with part of your post, however I think that you're mistaken that the DNPs will go ONLY for "bread/butter" stuff.

I break up the DNP into 2 phases. We are entering phase 1, which is all about what you talk about where the DNPs will take away all the bread/butter stuff and refer everything else out. FPs who dismiss the threat like bluedog either work in some weird FP practice where "complex" patients make up an unusually high volume of their practice, or they are just totally clueless and dont see the freight train headed in their direction.

At any rate, its an established FACT that most of the work done in FP clinics constitutes the "bread/butter" variety that DNPs want, and if the FPs lose it, they will go out of business, because Medicare and insurance are NOT going to pay them enough for the complex cases to make up for the loss of 60% of their base practice.

Thats why I find bluedog's attitude of "I dont have to worry about it, I have lots of complex patients that DNPs cant handle" so amusing. Like I said, he either works in a weird FP practice where there's no specialists available to handle the complex cases, OR he's just being disingenuous. At any rate, if he's at some kind of "complex patient" FP practice then its NOT representative of FP clinics at large and we should dismiss his experience out of hand because it wont apply to other FPs.

Where I disagree with you is that I believe that there is a "phase 2" to the DNP push, and this is where the specialties come into play. Lets all remember that Medicare/insurance reimburse **** wages for bread/butter stuff, so the DNPs have every intention of moving into the specialties. Once they get their "doctoral" degree they'll try to confuse the public by not just infiltrating primary care, but by setting up sham "residencies" in cardiology, GI, rheum, etc.

The DNPs want it all--first they'll try to steal the bread/butter primary care stuff, and later they'll try to move into the specialties.

 

[MacGyver]

I didnt say it was different.

Sad in all specialties with midlevel encroachment.

Your specialty has no room to complain. You were making 3 times the income of primary care docs LONG before CRNAs became the unstoppable force they are today. Yet you guys decided that wasnt enough. You werent happy making 350k, you wanted 450k so you sold your profession to the CRNAs.

MDAs are the worst of the physician sell-outs. General surgeons average about a 100k less than MDAs, yet you dont see them allowing midlevels to run surgeries solo do you? Meanwhile, your colleagues are busy changing the regs so they can "supervise" 3, 5, 7, 10, or 20 CRNAs at a time to increase their billings. What a shame.

 

[MacGyver]

That is a perfectly reasonable use of a DNP. What is not perfectly reasonable is for them to set up a solo practice in a little town pretend they are the local doctor.

Sorry, that ship has already sailed.

 

[Taurus]

The DNP's, once they are firmly established in primary care, will make the simple argument, "If we can do primary care, why can't we do specialty care?"

That's why DNP's need to be taken seriously by all physicians and why I think many medical groups have taken notice. Whether they can do anything about it is still up in the air.

I have made the commitment of never hiring a DNP. If I have to hire a midlevel, it will be a PA.

 

[MedicineDoc]

Basically what we have is a regression to the pre-Flexner report days. The question is who is going to deliver the smack down and protect the public if at all once medical care goes completely to ****.

 

[deleted87716]

From the members-only portion of the AAFP web site, reposted here because some of you may not be able to access it.

Editorial

Not Everyone in Nursing Agrees With Doctor of Nursing Practice Concept

By "Voices" Staff
4/9/2008

Physicians' collective blood pressure may have spiked after the Wall Street Journal published the article "Making Room for 'Dr. Nurse'" on April 2.

"As the shortage of primary care physicians mounts, the nursing profession is offering a possible solution: the 'doctor nurse,'" the article begins, highlighting the growing number of doctor of nursing practice, or DNP, programs in U.S. nursing schools.

Much of the article advances the viewpoint of Mary Mundinger, R.N., Dr.P.H., dean of New York's Columbia University School of Nursing. The article says that DNP programs equip graduates with skills "equivalent to primary care physicians." Mundinger characterizes the graduates as "hybrid" practitioners with more skills, knowledge and training than a nurse practitioner with a master's degree, and she says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health care settings.

The DNP's primary aim isn't to usurp the physician's role, Mundinger says, but instead is to deal with the fact that there simply won't be enough physicians to care for patients with increasingly complex care needs. It is not yet clear whether the DNP model of nursing practice will worsen nursing workforce shortages.

It's important to note that some nursing stakeholders don't agree with Mundinger and others behind the DNP concept. The WSJ article itself acknowledges this split in nursing, noting that the American Academy of Nurse Practitioners wants to ensure that its members won't be marginalized or required to return to school for a costly advanced degree.

Indeed, the American Association of Colleges of Nursing's own statements say that the DNP degree does not expand the scope of practice and does not prepare candidates to practice medicine. A "frequently asked questions" document about the DNP on the association's Web site says that "nursing and medicine are distinct health disciplines that prepare clinicians to assume different roles and meet different practice expectations. DNP programs will prepare nurses for the highest level of nursing practice. Transitioning to the DNP will not alter the current scope of practice for advanced practice nurses as outlined in each state's Nurse Practice Act."

It also is important to note that this is a broad physician-nurse issue. Although AAFP President Jim King, M.D., of Selmer, Tenn., was quoted in the WSJ article and provided a counterpoint to Mundinger's views, the truth is that the DNP issue isn't something family medicine is grappling with alone. The AMA Scope of Practice Partnership, to which the AAFP belongs, has established a task force to explore this issue further. The AAFP will continue to work with this coalition of national medical specialty organizations and state medical societies and in other collaborative venues to ensure the Academy is addressing members' needs.

 

[jetproppilot]

Your specialty has no room to complain. You were making 3 times the income of primary care docs LONG before CRNAs became the unstoppable force they are today. Yet you guys decided that wasnt enough. You werent happy making 350k, you wanted 450k so you sold your profession to the CRNAs.

MDAs are the worst of the physician sell-outs. General surgeons average about a 100k less than MDAs, yet you dont see them allowing midlevels to run surgeries solo do you? Meanwhile, your colleagues are busy changing the regs so they can "supervise" 3, 5, 7, 10, or 20 CRNAs at a time to increase their billings. What a shame.

Please see the Why Make 150K When 450K Is Out There? thread, Slim.

Post #461.

BTW, whats an MDA?

 

[racerx]

.

 

[sophiejane]

I don't know why your asking him/her when I answered that a while back, Clyde. See my earlier reply to you regarding your question, where I showed where one of your good friends also provided an interesting answer to this. Like your MDA colleague, perhaps you should spend more time on that forum. Your financial future will depend on them much more than it will on those of us in the FM forum.

A reminder:


Whether you like it or not, the term is out there and IS used -- by more than just a few people on here. It's a petty thing to be offended over, in the greater scheme of things.

The more I read, the more I think the "A" in MDA may stand for something else. . . and it isn't Anesthesiologist.

Just sayin'. . .

WE INTERRUPT THIS POST FOR A PUBLIC SERVICE ANNOUNCEMENT:

This is the new and improved kinder and gentler FM forum, people.

Personal attacks will not be tolerated.

Take it offline. Stick to the topic.

Thanks, and now back to our regularly scheduled thread.

 

[PHealthMan]

what a great deal of hubris exists in this thread. Advanced Practice Nurses not having the ability to understand the common/obvious issues challenging OB medicine? A Doctor of nursing who spent at minumum 3 years of advanced studies and an unknown amount of time outside of her/his formal education in studies unable to recognize joint pain and fever? Stop lumping professions into ONE category. DO not confuse the nurse pract. who just graduated with the one who has been in practice for 20 years and continued education, research, and patient care during that time. If you want to state that an NP without post grad training and only a few years of experience who does not exhibit intellectual vigor is not qualified to be in FP, FINE. But that is not every practitioner. And I am not an NP or RN.

 

[EdibleEgg]

They are not qualified. FP= Family PHYSICIAN.

 

[sophiejane]

DO not confuse the nurse pract. who just graduated with the one who has been in practice for 20 years and continued education, research, and patient care during that time. If you want to state that an NP without post grad training and only a few years of experience who does not exhibit intellectual vigor is not qualified to be in FP, FINE. But that is not every practitioner. And I am not an NP or RN.

I don't lump them all together. I recognize differing levels of experience. But the state does not. If the state says a first year DNP grad who went straight through school can have independent practice rights, then they can. They can put up a shingle and charge for services all the while calling themselves "doctor."

I don't have a problem with SUPERVISED NPs under a physician. I do have a problem with them calling themselves a doctor and having independent practice rights and a DEA number.

 

[deleted87716]

I am not an NP or RN.

That's right, you're a "physician assistant and self proclaimed public health sociologist." Not that there's anything wrong with that. 😉

 

[secretwave101]

Some Nurses Land Higher Salaries Than Primary Care Doctors

Given the amount nurse training costs, both in tuition and saved-time, if a nurse salary even approaches a physician's, they're winning the money game.