NYT Today: "Nurses are Not Doctors"

[DermViser]

icuRNmaggie

I don't get it.

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[fab4fan]

The advanced practice nurses' argument that they've been getting experience ever since they started clinicals in nursing school doesn't make sense. Their experience is in being a nurse, not a provider. While experience as a nurse helps in some areas (e.g. exposure to various disease processes, learning medications, etc.), it doesn't teach you how to be a provider. I do think there's definitely some benefit, but not nearly as much as some tout.

 

[BestDoctorEver]

The advanced practice nurses' argument that they've been getting experience ever since they started clinicals in nursing school doesn't make sense. Their experience is in being a nurse, not a provider. While experience as a nurse helps in some areas (e.g. exposure to various disease processes, learning medications, etc.), it doesn't teach you how to be a provider. I do think there's definitely some benefit, but not nearly as much as some tout.

Not only that, many NP schools accept applicants with no nursing experience whatsoever... These people are talking out of both sides of their mouth.

 

[DermViser]

Not only that, many NP schools accept applicants with no nursing experience whatsoever... These people are talking to the both sides of their mouth.

There even are NP programs that are online. That to me is very scary.

 

[BestDoctorEver]

There even are NP programs that are online. That to me is very scary.

I look at some of these NP schools curricula and I think they are simply scary... I just can't comprehend how the whole healthcare system including politicians get it so wrong.

 

[DermViser]

I look at some of these NP schools curricula and I think they are simply scary... I just can't comprehend how the whole healthcare system including politicians get it so wrong.

They don't care if they're wrong. When they are sick or their families are sick, they will demand an MD. NPs are for the unwashed masses.

 

[tdram]

They don't care if they're wrong. When they are sick or their families are sick, they will demand an MD. NPs are for the unwashed masses.

I've never ever seen or heard of anyone demanding an MD. Have you? I'd be curious to know. Most of the patients I talk to don't even know what degree their provider has.

 

[DermViser]

I've never ever seen or heard of anyone demanding an MD. Have you? I'd be curious to know. Most of the patients I talk to don't even know what degree their provider has.

My quote was referring specifically to politicians. You can bet if **** hits the fan, and a patient finds out that they've been treated the whole time by an NP they will be livid.

 

[tdram]

My quote was referring specifically to politicians. You can bet if **** hits the fan, and a patient finds out that they've been treated the whole time by an NP they will be livid.

Oh, I see. I agree if you mean politicians.

I think the problem is that when the **** does eventually hit the fan it may be hard to trace the mistake back to the NP.

 

[DermViser]

Oh, I see. I agree if you mean politicians.

I think the problem is that when the **** does eventually hit the fan it may be hard to trace the mistake back to the NP.

Not when they're the ones signing orders and signing their notes.

 

[ChrisGriffen]

.

 

[tdram]

Not when they're the ones signing orders and signing their notes.

But what about this scenario. Say the NP sees someone and fails to diagnose them properly. Their disease continues to brew and a couple years later they come into the MDs office with an end-stage disease. How could you trace the mistake back to the NP years ago?

 

[Winged Scapula]

But what about this scenario. Say the NP sees someone and fails to diagnose them properly. Their disease continues to brew and a couple years later they come into the MDs office with an end-stage disease. How could you trace the mistake back to the NP years ago?

Because they would have had signs of renal disease prior to ESRD which should have been picked up.

 

[tdram]

Because they would have had signs of renal disease prior to ESRD which should have been picked up.

I suppose that's true. But I wonder how many times a case like that gets traced back to the mistake. It's not easy to do (would require obtaining and reviewing numerous documents) would probably only be done if the there was a malpractice lawsuit.

So you would need to have a lot of people harmed badly before these mistakes start getting traced and a pattern builds up enough for the public to be alarmed about NPs.

Even then, the NPs seem to have the answer that doctors make mistakes too.

 

[@JackShephard]

It has already begun.

http://forums.studentdoctor.net/threads/nursing-physicians-and-clinicians.1079636/

Nursing Physicians and Clinicians
http://careers.unitedhealthgroup.com/career-areas/nursing-physicians-and-clinicians.aspx

Nursing Physicians and Clinicians Careers at UnitedHealth Group.
There’s an energy and excitement here, a shared mission to improve the lives of others as well as our own. A passion for excellence you won’t find anywhere else. We ask tough questions. We push ourselves and each other to find smarter solutions. The result is a culture of performance that’s driving the health care industry forward. Nursing here isn’t for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Learn more, and start doing your life’s best work.SM

I'm guessing this doesn't end well for physicians.

 

[@JackShephard]

Birdstrike is a poster in the EM forums, his post was excellent:

To Emergency Physicians who think midlevels "minimize" you


Right now, the way you have it set up is this:

If everything goes right with a patient, "Good job mid level." (You break even)

If something goes wrong with a patient, "Nice screw up ER doctor. Way to screw up your supervisory role, doc. Way to negligently give your midlevel too much independence." (You lose here).

Midlevel sees easy patients, you see the hardest most grueling.

You increase your liability.

Midlevel works the busiest shifts (always the swing shift) leaving nights for you.

You're told midlevels allow you to make more money, though you're not really sure you've ever seen an extra penny. (When's the last time you added a midlevel, and then got a pay raise or a bonus check because of it?)


The only minimizing of you is when you consign the chart and take all of the liability. The midlevel doesn't minimize you. You minimize you.

How do you ever, EVER, expect the world to know you are better, higher trained, than a midlevel, if you allow yourself to work with midlevels, in a scenario that's is

Lose, or break even, at best?

(If everything goes right, "That's how it should be." If anything goes wrong, "Doctor screwed up, by not supervising well enough.")

This scenario is created by you co-signing charts, or agreeing to be listed as a "supervising doctor" on med-mal policies, and in hospital by laws.


DOCTORS ARE TO BLAME FOR THIS


Do not blame, or resent the mid-levels for this. Why the doctor/mid-level arrangement works better in other specialties (particularly the surgical ones) is because of the fact that they have not completely lost control of their specialties, their practice lives and autonomy, as Emergency Medicine has.

So complain all you want about midlevels "minimizing" you, but as long as you keep consigning charts, you're just minimizing yourself by taking all the liability, and all the blame when anything goes wrong. Only if any practitioner has to stand alone, and defend his practice alone, and buy his med-mal policy alone, and get hospital credentials alone, do you have any prayer in hell of showing you are any better.

I agree with this, how this will play out is:

- Give the midlevels the easiest cases, if they succeed they prove their worth and save on costs. If they fail, the supervising physician is to blame and will be liable in malpractice cases (the midlevel was in over his/her head!). Edit: also in EM specifically, the midlevels will avoid all the overnight shifts - which essentially is the same principle - midlevels take the easiest patients and easiest parts of the physicians job.

This worked well in anesthesia because you have risk assessments and an extensive workup to determine the ASA status. For other patients, it's not always clear who is a high risk or low risk patient.

Physicians will take all the losses and the midlevels will take all the wins.

 

[Winged Scapula]

I suppose that's true. But I wonder how many times a case like that gets traced back to the mistake. It's not easy to do (would require obtaining and reviewing numerous documents) would probably only be done if the there was a malpractice lawsuit.

So you would need to have a lot of people harmed badly before these mistakes start getting traced and a pattern builds up enough for the public to be alarmed about NPs.

Even then, the NPs seem to have the answer that doctors make mistakes too.

It's not that hard in this day and age of EHRs; I can see patient records from several years back on multiple systems. But until someone suffers an aggregious injury and is famous or politically well connected, I can't see much changing.

I did have a nice opportunity to explain to a patient why I don't operate at a certain hospital (only CRNAs) and the husband told me they had an anesthesiologist. I showed him the operative report they had which was templated with the header Anesthesiologist but signed XX, CRNA. He was duly upset saying, "how am I supposed to know the difference?" To which I explained that's what is being counted on: patient ignorance.

 

[tdram]

Birdstrike is a poster in the EM forums, his post was excellent:



I agree with this, how this will play out is:

- Give the midlevels the easiest cases, if they succeed they prove their worth and save on costs. If they fail, the supervising physician was a bad manager and he/she will be liable.

This worked well in anesthesia because you have risk assessments and a variety of tests to determine the ASA status. For other patients, it's not always clear who is a high risk or low risk patient.

Physicians will take all the losses and the midlevels will take all the wins.

Why do physicians keep allowing this to happen? Physicians have the power, at least now, because the midlevels still need the Doctor's approval. Why not use it to curb midlevels enchroachment? Refuse to sign off. Don't hire them. Don't refer to people who use them?

I am a naive medical student so I may not understand what's going on behind the scenes. If there's a reason this can't be done, please correct me.

 

[@JackShephard]

Why do physicians keep allowing this to happen? Physicians have the power, at least now, because the midlevels still need the Doctor's approval.

The issue is that they can hire someone else to do the job.

Physicians don't have the power because government regulations, interventions and increasing complexity have made it increasingly difficult to own a private practice. More and more physicians are becoming employees. Managing billing, EHR, and documentation are careers in and of themselves. Just like there's an entire career dedicated to filling out your taxes each year. Complexity has created new careers.

 

[Winged Scapula]

I've not read through this entire thread due to time factors but thought those most interested would care to know that my sleuthing about your recent troll found that she is indeed a nurse, foreign trained. not a PhD student, and states that she is currently working as a graduate assistant (I couldn't find out what department) at a less than prestigious school (a real school though, not University of Phoenix).

 

[Winged Scapula]

Why do physicians keep allowing this to happen? Physicians have the power, at least now, because the midlevels still need the Doctor's approval. Why not use it to curb midlevels enchroachment? Refuse to sign off. Don't hire them. Don't refer to people who use them?

I am a naive medical student so I may not understand what's going on behind the scenes. If there's a reason this can't be done, please correct me.

Because of money.

My business partner hired a PA several years ago (after I told her that politically I preferred PA over RN/NP); her PA allows her to see more patients and bring home more money. This partner also works at the hospital above with only CRNAs. For some physicians, including my partner, the desire for more money trumps any concerns about encroachment (although honestly I don't think my partner is the least bit educated about the politics except what I've told her when she's suggested that I get a PA).

 

[tdram]

The issue is that they can hire someone else to do the job.

Physicians don't have the power because government regulations, interventions and increasing complexity have made it increasingly difficult to own a private practice. More and more physicians are becoming employees. Managing billing, EHR, and documentation are careers in and of themselves. Just like there's an entire career dedicated to filling out your taxes each year. Complexity has created new careers.

So does that mean there's nothing we can do? Is it hopeless?

 

[@JackShephard]

So does that mean there's nothing we can do? Is it hopeless?

Define hopeless.

As American physicians, we will be in a higher income earning and social status than 99% of the people on earth. We live with more conveniences than kings of old.

As for the role of the American physician (excluding surgeons)? It's not looking that great. Yet, we'll all still be better off than 99% of people on earth...

 

[tdram]

Define hopeless.

As American physicians, we will be in a higher income earning and social status than 99% of the people on earth. We live with more conveniences than kings of old.

As for the role of the American physician (excluding surgeons)? It's not looking that great. Yet, we'll all still be better off than 99% of people on earth...

You only need to be making about $34k to be in the top 1% of the world (http://www.dailymail.co.uk/news/art...obal-elite--half-worlds-richest-live-U-S.html), so that encompasses a majority of Americans, not just physicians. Therefore you could make that argument for pretty much any professional in America, or really any job at all. Pretty much every American has more conveniences than the kings of old too...

I think there's more to a job than money and social status. The social status is also not likely to stick around, if pretty much anyone can get an online degree, put on a white coat and be a "doctor", practicing independently. As we already established, the patient's dont really know the difference. It severely reduces the glamour/status associated with a doctor when the barrier to entry drops so significantly. Doctors had a high status precisely because it was really tough to become one.

It seems like medicine is heading in a direction where the job is less and less tolerable. To me, if that trend can't be reversed, it seems hopeless. A continous downward slope that cannot be turned around is pretty much the definition of hopelessness.

 

[@JackShephard]

It seems like medicine is heading in a direction where the job is less and less tolerable. To me, if that trend can't be reversed, it seems hopeless. A continous downward slope that cannot be turned around is pretty much the definition of hopelessness.

Well, you answered your question then. It all depends on how you define hopeless.

 

[Psai]

Define hopeless.

As American physicians, we will be in a higher income earning and social status than 99% of the people on earth. We live with more conveniences than kings of old.

As for the role of the American physician (excluding surgeons)? It's not looking that great. Yet, we'll all still be better off than 99% of people on earth...

Man this is such a premed argument. How does this have to do with anything? It's not even relevant to the thread

 

[@JackShephard]

Man this is such a premed argument. How does this have to do with anything? It's not even relevant to the thread

I understand anything that has hints of idealism is considered juvenile and pre-med thought.

What does it have to do with the thread? Well, when people talk about how bad things are you can count all the things you have to be grateful for or just talk about how hopeless the situation is.

But you're right, it's not relevant to the thread - so we can forget I said it and just move on.

 

[BestDoctorEver]

Because of money.

My business partner hired a PA several years ago (after I told her that politically I preferred PA over RN/NP); her PA allows her to see more patients and bring home more money. This partner also works at the hospital above with only CRNAs. For some physicians, including my partner, the desire for more money trumps any concerns about encroachment (although honestly I don't think my partner is the least bit educated about the politics except what I've told her when she's suggested that I get a PA).

Why can't all doctor start doing that--hire PA instead of NP? Are physicians making it easier for NP to undermine the medical profession?

 

[tdram]

Why can't all doctor start doing that--hire PA instead of NP? Are physicians making it easier for NP to undermine the medical profession?

They certainly could do that, I don't know why they go for the NP in general. However, I did hear a couple of doctors here saying that the NP is better because they're completely independent in this state so it's easier for the docs (no need to sign off on their work).

 

[DermViser]

It amazes me to see how some individuals seem "appalled" by nurses or the nursing profession. At the end of the day, there is nothing that can replace a "doctor." However, one thing is evident........the world of nursing and the world of medicine must learn to get along and respect each for what that profession brings to the table. At the end of the day, it is about the patient.......not your hate or disgust for nursing. You can't compare the educational requirements because they are DIFFERENT professions. Nurses begin their education with hands on experience with patience from day one.......this is what helps build their knowledge base in conjunction with the required academic courses. Working at a teaching hospital, I have witnessed first-hand how residents rely on the information the nurse provides concerning the patient's care and condition. Working in the private setting, the attendings expect the nurse's to understand the patient's conditions and to be able to relate any significant changes observed. It is the nurse that is at the bedside during a patient's illness......not the doctor.

It would be futile for anyone to attempt to argue a DNP being equivalent to a MD........that would be absurd! A nurse who has obtained a DNP is still governed by their states Board of Nursing. If the medical profession did not need the nursing profession........nursing would have phased out decades ago........

Nice white coat....

 

[Brain Bucket]

Jesus, why do I bother. Disregard this please.

 

[Winged Scapula]

They certainly could do that, I don't know why they go for the NP in general. However, I did hear a couple of doctors here saying that the NP is better because they're completely independent in this state so it's easier for the docs (no need to sign off on their work).

Complete independence is the EXACT reason we don't have an NP. Then again we are in a high litigation specialty and are somewhat risk averse.

 

[Gifted Hands]

Why can't all doctor start doing that--hire PA instead of NP? Are physicians making it easier for NP to undermine the medical profession?

Because the healthcare landscape has changed, less physicians are in private practice due to the high overhead and increasing admin red tape, so those hiring decisions are left to the administrators for the hospital/practice you work for. You are an employee.

 

[tdram]

Because the healthcare landscape has changed, less physicians are in private practice due to the high overhead and increasing admin red tape, so those hiring decisions are left to the administrators for the hospital/practice you work for. You are an employee.

Aren't those administrators often physicians themselves?

 

[DermViser]

Aren't those administrators often physicians themselves?

keywords: non-full time clinical practicing administrators. Many of them are MD/MBAs for a very good reason. It's a good "out" from medicine (just in case).

 

[Winged Scapula]

Aren't those administrators often physicians themselves?

Many times they are not but rather a business or hospital admin degreed individual.

 

[DermViser]

It's not that hard in this day and age of EHRs; I can see patient records from several years back on multiple systems. But until someone suffers an aggregious injury and is famous or politically well connected, I can't see much changing.

I did have a nice opportunity to explain to a patient why I don't operate at a certain hospital (only CRNAs) and the husband told me they had an anesthesiologist. I showed him the operative report they had which was templated with the header Anesthesiologist but signed XX, CRNA. He was duly upset saying, "how am I supposed to know the difference?" To which I explained that's what is being counted on: patient ignorance.

And if you had worked for a hospital and said that, they would have labeled you "unprofessional" or "disruptive".

 

[Winged Scapula]

And if you had worked for a hospital and said that, they would have labeled you "unprofessional" or "disruptive".

Lol...yes they would have.

Apparently one of the OR staff recently reported my business partner and a plastic surgeon for making the OR "uncomfortable". The surgeons were bumped by an emergent carotid take back and were delayed several hours (the plastic surgeon is claiming 5 hrs but I was there that day and think it was more like 3) and were apparently bitching about the delay and the fact that the OR desk didn't move them into another room. Guess the OR staff (who don't so room bookings) took it personally.

Another friend, a *black* Gyn Onc got reported for saying, "this place is so ghetto" when she inquired about a piece of equipment that they didn't have.

I got written up several years ago when asked ( as if I was his mother or his business partner) where the plastic surgeon was (one who had a history of not showing for cases, so I was a bit nervous) and I replied, "How the hell would I know?"

I learned my lesson to keep my trap shut because someone is always out to make a mountain out of a molehill. And to think we have surgeons SCREAMING at OR staff and this is what gets written up.

 

[DermViser]

Lol...yes they would have.

Apparently one of the OR staff recently reported my business partner and a plastic surgeon for making the OR "uncomfortable". The surgeons were bumped by an emergent carotid take back and were delayed several hours (the plastic surgeon is claiming 5 hrs but I was there that day and think it was more like 3) and were apparently bitching about the delay and the fact that the OR desk didn't move them into another room. Guess the OR staff (who don't so room bookings) took it personally.

Another friend, a *black* Gyn Onc got reported for saying, "this place is so ghetto" when she inquired about a piece of equipment that they didn't have.

I got written up several years ago when asked ( as if I was his mother or his business partner) where the plastic surgeon was (one who had a history of not showing for cases, so I was a bit nervous) and I replied, "How the hell would I know?"

I learned my lesson to keep my trap shut because someone is always out to make a mountain out of a molehill. And to think we have surgeons SCREAMING at OR staff and this is what gets written up.

Unfreakingbelievable. Yet somehow allowing reporting is supposed to make things better. Now it's used as a way for non-physicians to "get back" at physicians to put them in their place. They should allow them to fill out Press-Ganey cards on doctors (sarcasm).

 

[DrJonesenberg]

Michigan is about to be added to the list of autonomous APRNs

This is how I feel about nurses trying to be doctors every time I see this stuff except replace "famous" with "doctor"

 

[Frazier]

Lol...yes they would have.

Apparently one of the OR staff recently reported my business partner and a plastic surgeon for making the OR "uncomfortable". The surgeons were bumped by an emergent carotid take back and were delayed several hours (the plastic surgeon is claiming 5 hrs but I was there that day and think it was more like 3) and were apparently bitching about the delay and the fact that the OR desk didn't move them into another room. Guess the OR staff (who don't so room bookings) took it personally.

Another friend, a *black* Gyn Onc got reported for saying, "this place is so ghetto" when she inquired about a piece of equipment that they didn't have.

I got written up several years ago when asked ( as if I was his mother or his business partner) where the plastic surgeon was (one who had a history of not showing for cases, so I was a bit nervous) and I replied, "How the hell would I know?"

I learned my lesson to keep my trap shut because someone is always out to make a mountain out of a molehill. And to think we have surgeons SCREAMING at OR staff and this is what gets written up.

What are the consequences of these notes of being "unprofessional"/adjective for the physician getting written up?

 

[fab4fan]

I've never ever seen or heard of anyone demanding an MD. Have you? I'd be curious to know. Most of the patients I talk to don't even know what degree their provider has.

I have. In fact, I changed surgeons when I found out the surgeon I originally planned to have for my surgery turfs all of his hospital follow-up to his PA, and most of the office visits, too. This was a complex surgery, and I wasn't going to take any chances. Turns out I was much better off going with the second surgeon. My ability to walk was on the line, so I wasn't going to leave that in the hands of his PA, no matter competent he may have been.

 

[tdram]

I have. In fact, I changed surgeons when I found out the surgeon I originally planned to have for my surgery turfs all of his hospital follow-up to his PA, and most of the office visits, too. This was a complex surgery, and I wasn't going to take any chances. Turns out I was much better off going with the second surgeon. My ability to walk was on the line, so I wasn't going to leave that in the hands of his PA, no matter competent he may have been.

That was a good choice. If only all patients were as informed as you. The PA has a place, but the surgeon should always remain involved in the patient's care. We should insist as patients that doctors not turf us out completely to PAs.

 

[tdram]

Michigan is about to be added to the list of autonomous APRNs

This is how I feel about nurses trying to be doctors every time I see this stuff except replace "famous" with "doctor"

I sometimes wonder what the point of licensing for healthcare providers at all is, if they're going to give it out based on political influence more than actual capability.

Maybe we're better off doing away with government licensing completely. That would incentivize the physicians to educate the public more about their qualifications and push the patients to do more research into a provider's credentials before choosing one. It would also bring about private licensing agencies which would compete with each other to provide the best and most reliable licenses, which would probably be at the worst just as good as the government system that yuo can apparently buy yourself into with power and money, and at best a very effective system because bad / corrupt licensing would give other companies significant competitive advantage and ruin the company's business, as there would be no monopoly on licensing the way the government has it now.

 

[fab4fan]

Lol...yes they would have.

Apparently one of the OR staff recently reported my business partner and a plastic surgeon for making the OR "uncomfortable". The surgeons were bumped by an emergent carotid take back and were delayed several hours (the plastic surgeon is claiming 5 hrs but I was there that day and think it was more like 3) and were apparently bitching about the delay and the fact that the OR desk didn't move them into another room. Guess the OR staff (who don't so room bookings) took it personally.

Another friend, a *black* Gyn Onc got reported for saying, "this place is so ghetto" when she inquired about a piece of equipment that they didn't have.

I got written up several years ago when asked ( as if I was his mother or his business partner) where the plastic surgeon was (one who had a history of not showing for cases, so I was a bit nervous) and I replied, "How the hell would I know?"

I learned my lesson to keep my trap shut because someone is always out to make a mountain out of a molehill. And to think we have surgeons SCREAMING at OR staff and this is what gets written up.

Looks like I would have gotten in trouble for the third instance, since my answer to that question is sometimes, "It's not my turn to watch him."

 

[Winged Scapula]

What are the consequences of these notes of being "unprofessional"/adjective for the physician getting written up?

They get reviewed by a committee who then decides if any further action needs to be taken. Nothing has happened in the three situations I mentioned above although I suppose there's something in my "permanent record".

 

[Baller MD]

They get reviewed by a committee who then decides if any further action needs to be taken. Nothing has happened in the three situations I mentioned above although I suppose there's something in my "permanent record".

You should threaten to take your talents to the hospital down the street.

 

[Winged Scapula]

You should threaten to take your talents to the hospital down the street.

Oh believe me, I pull that arrow out of my quiver on occasion for something really important. If I use it too often it will lose its effectiveness.

 

[fancymylotus]

Oh believe me, I pull that arrow out of my quiver on occasion for something really important. If I use it too often it will lose its effectiveness.

 

[WhippleWhileWeWork]

A few of you have pointed out the hypocrisy of Big Nursing, so I thought you'd enjoy this. On a All Nurses thread about Nurses taking over respiratory work in hospitals someone said this,

"It's more a matter of "taking back" than "taking over." RT is yet another of those occupations that was spun off from nursing. Back in the day, everything that was done for people outside of actually ordering the medications (physician) was nursing practice, and done by nurses. Over the decades/generations, RT, PT, OT, etc., all got spun off as separate fields. When I started in nursing a long time ago, we had RTs in ICU, but all the respiratory stuff on the floors was done by the RNs. It's not that big a deal. Many of us, over the years, have been concerned about how much of nursing practice we have "given away" to other groups."