Nurses Run the Show

[secretwave101]

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Remember, this post was initially not really about DNP specifically, but the argument that FP's need to be involved with political decision-making.

Below, I've posted a comment from a reader of the the article link in the above post. The reader is an internist, but it sums up the problem well, I think:

Primary care Physician pay in the USA is inappropriately low. Every specialist in the USA knows and realizes it deep down. Medial students are voting with their feet. We are well and truly at an inflection point. No longer are sufficient number of doctors entering primary care for it to remain physician led. Unfortunately the changes are gradual and in an expensive and archaic way covered up by specialty care access and increased use of testing modalities. If we continue down this path, the results will only fully become apparent in another generation or so, when doctors would have completely exited the retail PCP scene. Unfortunately by then the infrastructure to train future PCPs would have been dismantled. The notion of a Nurse out-earning a PCP is simply astonishing and just another example of a RVU system which is skewed against cognitive services.

 

[aminoacid]

How many of these people are being trained by physicians? How many physicians are using midlevels vs. their peers [surgeons using CRNA's vs. anesthesiologists, FM docs pushing for Rx psychologists (or using them in NM & LA) vs. psychiatrists, primary care docs referring to a midwife vs. an OB, etc.]. Instead of us blaming others for exploiting the greed of some of us (unfortunately, we do exist), we should unite to stop the current self-destructive path we're on as a profession.

 

[Faebinder]

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.

Many nurses manipulate their overtime to get more return. It's not uncommon to hear of a nurse that makes 120k in places like california. Hospital crazy pays are the reason primary care has little pay.

 

[Taurus]

For 2007, the highest paid municipal worker in San Francisco is a nurse. How much? $350,324.

Citywide rank (total pay) 1
Employee name CHRISTIAN KITCHIN
Title SPECIAL NURSE
Department DPH-Community Health Network
Regular pay $117,262
Overtime pay $216,277
Other pay $16,785
Total pay $350,324​

 

[MOHS_01]

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.

OK -- I'll be the bad, politically incorrect guy (who is fundamentally correct, technically accurate, and generally wearied overall regarding this whole "mid-levels are anywhere near equals" BS)...

10, 20, or even 30 years of "on the job training" does not make one qualified or great. To insinuate or frankly suggest that a mid-level provider is even remotely equivalent to a duly trained MD demonstrate either a fundamental lack of understanding of the medical education process or a less than genuine propaganda push.

Let us not forget the talent pool from which MD's have traditionally been selected, and view said talent pool in direct comparison to those who choose nursing or other allied health careers. Greater talents (generally, there will always be exceptions) from the start, many of who experience difficulty with the arduous educational, training, and work hour requirements of the medical education process. The simple fact of the matter is that lesser gifted individuals could not hack it (as well as the fact that many who do make it through medical school should have been weeded out after the first year or two, but that is another rant for another day).

Flame on, but the truth of the matter is that I expect the highest level of care for my friends and family, and for everything but splinters and allergic rhinitis upon exposure to mowing the lawn I expect an MD to see and lay hands on....

Least of all is to mention the fact that I spent more hours waiting for a nurse to give meds, finish their "charting", or check vitals my intern year than a DNP is required for training.... what a f'ing joke.

 

[secretwave101]

One difficulty I have with the current trend is that the two types of training have traditionally been totally different and complimentary. Doctors are trained to diagnose and treat, relying on wide differentials and treatment outcome evidence. Nurses were trained to recognize status changes and make sure care plans are implemented accurately.

Nurses are now being trained to diagnose and treat patients based on the notion that certain elements of the medical field don't necessitate flexner-level medical training. This is nothing more than cut-rate med school. We need to either dispense with the notion of medical school as antiquated and inefficiently expensive, or we need to reinforce the delineation between doctor training and nurse training.

 

[sophiejane]

One difficulty I have with the current trend is that the two types of training have traditionally been totally different and complimentary. Doctors are trained to diagnose and treat, relying on wide differentials and treatment outcome evidence. Nurses were trained to recognize status changes and make sure care plans are implemented accurately.

Nurses are now being trained to diagnose and treat patients based on the notion that certain elements of the medical field don't necessitate flexner-level medical training. This is nothing more than cut-rate med school. We need to either dispense with the notion of medical school as antiquated and inefficiently expensive, or we need to reinforce the delineation between doctor training and nurse training.

Exactly. Completely different model.

AND NO RESIDENCY!

I can't imagine practicing today, with the level of complexity of medical care, without residency.

 

[dejerine]

Taurus, you might also add the fact that the DPH is paying her malpractice, which if she were in a tougher field than public health, would be considerable. Doctors will have to unionize, sooner or later, and fight for their rights through collective bargaining, or they will lose them. Some of this is supply and demand. Our hand is weakened as the requirement for licensure is watered down. I do not see evidence of this happening, so managed care experts will do an end around by favoring nurses privileges to provide primary care.

The public, especially people with salaries of 300,000 are not going to give up without a fight. If we do give up, we are apathetic do-nothings. In this case, it is a matter of what is good for doctors is good for the public.

Fortunately, we have sufficient numbers of well trained female doctors to avoid making this an issue of gender. I think they will spearhead the public information that nurses training simply cannot be equated with the rigor and sophistication of medicine.

How about a doctors degree for orderlies, or maybe phlebotomists. Pharmacists in La may already prescribe medicine, and their training is considerably more involved than NP, requiring a PhD and hospital training. However, all prior pharmacits were grandfathered in, as I understand it and given a doctorate..

There is also a crisis going on in nursing where many hospitals do not allow RN's to wear nametags with that designation, so they can hire warm bodies and put them in scrubs. Patients do not know the difference. Managed care is more "managed" than "care" when this sort of thing gets going. Much of this is necessitated by awarding such high salaries to the bigwigs in managed care. Administrators currently skim off 37% of the hospital dollar. You could hire a lot of docs with that kind of money.

 

[Faebinder]

The solution is simple but hard. Move physician/patient encounter away from the hospital as much as possible. Cut out the middle man. Surgicenters, light medical centers and whatever centers that dont empower a nurse union helps cut down costs and bargaining power while returning bargaining power to the physician.

The problem is that being independant has become nearly impossible in medicine cause it has less $$ return and hospitals try to impose their power to stop things from being built to compete with them.

 

[MOHS_01]

The solution is simple but hard. Move physician/patient encounter away from the hospital as much as possible. Cut out the middle man. Surgicenters, light medical centers and whatever centers that dont empower a nurse union helps cut down costs and bargaining power while returning bargaining power to the physician.

The problem is that being independant has become nearly impossible in medicine cause it has less $$ return and hospitals try to impose their power to stop things from being built to compete with them.

Faebinder,

This potential avenue of recourse was plausible ten years ago, not so much now. Between the evolution of the Stark laws to the increased regulation (and prosecution) of physician self referral interests, pursuit of this expensive undertaking would be assuming a huge financial risk at best. Physician owned specialty centers / hospitals are already dead center on the screen of public policy radar....

 

[DrDre311]

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.

That's the problem with this "degree." You can get it online and on weekends. There is NO standardization of this so-called "doctorate." There is NO requirement to take a national board examination (it's optional--imagine if the USMLE were optional). There's no way to ensure an equivalent level of training among DNP's.

If someone exhibits the intellectual vigor to practice medicine, that person should go to medical school. I'm sure there are very intelligent NP's/DNP's who do good work. But anecdotally, I can't tell you how many times I've seen someone in the ED--first as a student, then as a resident at a different institution--with some medical issue being completely mismanaged by his/her "doctor" and when you ask the patient who his/her doctor is you find out it's actually a nurse. Most patients I've seen can't tell the difference among any of the white coats who take care of them; medical students, residents, fellows, attendings, DNP's, etc. are all consolidated into "doctors" in the minds of average patients. The issue isn't the intelligence or skill or individual practitioners; the issue is a fundamental difference in the method and content of training programs for entirely different branches of healthcare.

Good nurses make for great patient care, but there are a lot of not-so-great nurses that, most of the time, just make me want to bang my head against a wall. In my experience a nurse's understanding of basic physiology/pathophysiology/pharmacology/anatomy is incredibly superficial. Don't believe me? Next time you have a question about one of your patients, ask the nurse taking care of the patient, even one with an advanced nursing degree, what he/she thinks. Then, when he/she gives you an answer based simply on what he/she has seen done in the past, or "that's just what we do here"--ask why. Ask the nurse why he/she gave you that answer. In my experience, you're not going to be handed an article or get a detailed discourse even on simple issues, such as exactly how macrolide antibiotics work, the mechanism of CPP autoregulation, or why renal artery stenosis can cause hypertension--you'll get some hemming and hawing that can be summed up as "just because." Then ask your attending/upper-level (or even yourself) the same question and see how the answer differs.

We need good nurses, I love good nurses, and I'm all for professional behavior and being part of a multidisciplinary team. I just take issue with the militant DNP/CRNA agenda because physician-level medical training and nurse/DNP/CRNA training are fundamentally different, from the very beginning, and therefore can never be equivalent. The U.S. medical system is broken and we need to fix it--and I admit that I don't have a great way to do it--but I don't think creating a class of pseudo-doctors when the public doesn't know the difference is the answer.

 

[m3unsure]

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.

This gotta be a troll nurse of some sort. Hey, I know a cardiology NP back when I was an intern. She was in the game for like 8 years. That's plenty of time to then assess the role of an NP. I'm not saying she was a dummie since she knew a lot more about pattern recognition than I did when I started intern year, but when we get to the end, guess who knows more about managing other stuff in a patient besides the cards.

Most NPs are one trick ponies, and they are really good at that one trick. It doesn't make them better and capable with all aspects of medicine. The same goes with CRNAs and MDs. They can do that lappy appy in a fairly healthy patient, but things change when stuff hits the fan. Guess who runs into the OR and manages the situation cerebrally. Not another CRNA. That's why docs exist even if they are just there for oversight. And from what I hear, most don't like to oversee 4-5 CRNAs. It gets hairy. Remember, anesthesia was practiced by dentists first, then nurses and docs. And docs made it safe, nurses didn't do jack except listen to surgeon commands. So how did they make anesthesia safe?

Same goes with FP. All they know how to do is read those one page summaries written by docs and then claim equivalent knowledge. Second, the technical skills no matter what specialty it is can be the same. Hell, my surgery attendings back in school let me do the whole c-section practically on my own with just guidance. I had spatial perception so I was set, but he was the one who knew when to hit the OR in terms of risks and benefits, not me.

Let's forget about how one specialty makes more than another. The problem is that people are picking doctor's pocket. Why have civil war when there is an enemy abroad? Make sure to hammer your legislators. All of us have worked hard plus have debt.

And by the way, I heard that some nurses are already facing litigation issues and premiums. So that previous post about them taking over is going to be harder for them then they think. Hell, if FP or anesthesiology pay drops, guess who would be valued less too. Bittersweet.