NYT Today: "Nurses are Not Doctors"

[radkat101]

One of the thing that makes me so interested in working in an international context/global health is that doctors in most other countries I have been are actually respected for the work they do, and the ability/time/effort/sacrifice required to get there.

I haven't seen nurses or mid levels of any kind pursue power, influence, and autonomy the way their professional orgs do in the US. In other places the only problems I have seen b/w docs and nurses is more the occasional physician not valuing the training and skill set of the nursing staff, techs, etc. America seems to be the only country with the opposite problem. Although I have no experience with Western Europe, so I guess it could be similar there too.

Interesting. I did a little research and it seems that even in western Europe, mid-levels are pretty much nonexistent. Any ideas what it is about these systems that make this a non-issue?

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[BestDoctorEver]

I think @DermViser has a good idea... They should phase out PCP for med students and let NP/PA take over. But the public might be outraged about that.

 

[DermViser]

I think @DermViser has a good idea... They should phase out PCP for med students and let NP/PA take over. But the public might be outraged about that.

Of course they would. The govt. and hospitals would LOVE it for primary care to be completely done by an NP or PA from a salary standpoint. However, the public is very reluctant to give up their doctors, esp. after the whole, "if you like your doctor, you can keep your doctor" fiasco.

However, I don't believe future medical students should have to fork out six figure tuition for a field that a) salaries end up being ratcheted down to compete with NP/PAs who get same reimbursement or b) where your entire work is mainly administrative where you are responsible for the actions of the NP/PA. So far the "Primary Care is important to us" line has proven to be BS, bc actions speak much louder than words. P4P ill only make it worse for generalists vs. specialists.

 

[dap]

Interesting. I did a little research and it seems that even in western Europe, mid-levels are pretty much nonexistent. Any ideas what it is about these systems that make this a non-issue?

Honestly that question is above my pay grade. But I think the better way to ask it is: what is it about our system (and probably our culture, history, etc.) that makes this an issue? It seems to be not only an American phenomenon, but a relatively recent American phenomenon. But any reasons I give would be not only speculation, but speculation from a pre-med with more experience with healthcare in places like Iraq than in the US...

 

[InGen]

Dear god, I just went over to that allnurses thread to see what was going on. I give up on the internet for today...

 

[DermViser]

Dear god, I just went over to that allnurses thread to see what was going on. I give up on the internet for today...

I'll just say, I love Susie 2310:

I agree that the clinical importance of the physician's expertise is being underestimated. I am sure too that the cost-effectiveness of nurse practitioners is being over-estimated.

Nurse practitioner training at the master's level involves around 600 hours of clinical training or less according to the web sites of prominent universities I checked. This is but a fraction of the number of clinical hours of training a physician receives. A physician generally has a bachelor's degree in a science, attends medical school for four years, and spends several more years doing residencies, internships and fellowships. To train as a Nurse Practitioner one is required to be an RN, with a BSN, and NP schooling is generally three years.

Most people would agree that a physician undergoes a far more rigorous and extensive training. Because of physicians extensive training in medicine, my family and I choose to receive our medical care from physicians. If someone is standing in front of myself or my family, and is presuming to diagnose and treat us, they are presenting themself as a medical authority, and we are only willing to accept physicians as medical authorities.

 

[Psai]

Yeah I saw that post and it was awesome. It sounded like something that would be posted here.

 

[DermViser]

Yeah I saw that post and it was awesome. It sounded like something that would be posted here.

Sadly it's the militant ones that are the loudest, drowning out the sane ones. The nurses I've worked with actually ENJOY what they do, and have no desire to become NPs as a backdoor to escape nursing.

 

[NontradCA]

Sadly it's the militant ones that are the loudest, drowning out the sane ones. The nurses I've worked with actually ENJOY what they do, and have no desire to become NPs as a backdoor to escape nursing.

The problem is that you will never see the outcomes as being worse. I don't think NPs are going to be reimbursed the same as physicians. There are several reasons for this. If given a choice of seeing a PCP, the layman will almost always choose a physician over a NP. The issue is that NP will be employed by hospitals as we move towards hospital based care, or they will be employed independently of a physician through a PCP group. However, physicians, having no choice of opening PP will have to work for these groups/hospitals and be given the more difficult/complex patients. The groups/hospitals will pay the NPs the same, and just hire physicians in more of an administrative role.

That being said, the rhetoric on that site is ridiculous and common sense escapes most of the nurses on there.

 

[DermViser]

The problem is that you will never see the outcomes as being worse. I don't think NPs are going to be reimbursed the same as physicians. There are several reasons for this. If given a choice of seeing a PCP, the layman will almost always choose a physician over a NP. The issue is that NP will be employed by hospitals as we move towards hospital based care, or they will be employed independently of a physician through a PCP group. However, physicians, having no choice of opening PP will have to work for these groups/hospitals and be given the more difficult/complex patients. The groups/hospitals will pay the NPs the same, and just hire physicians in more of an administrative role.

That being said, the rhetoric on that site is ridiculous and common sense escapes most of the nurses on there.

Reimbursement values are contracts between an entity (provider or hospital) and an insurance company. If a person's insurance through his work, has a preferred in-network provider as an NP, then the person will see the NP, or risk having to pay even more out of pocket, which he/she is not likely to do. The only thing stopping insurance companies from doing this is losing loads of customers which then decreases profit margins too much. That fear is what keeps this at bay.

Scope of practice is decided by state legislatures not hospitals or a group.

 

[WhippleWhileWeWork]

The problem is that you will never see the outcomes as being worse. I don't think NPs are going to be reimbursed the same as physicians. There are several reasons for this. If given a choice of seeing a PCP, the layman will almost always choose a physician over a NP.

I'm not sure about this, my tongue is actually shorter now from all the biting than it was 3 years ago when I started paying attention to all the people who tell me they'd "rather see a Nurse Practitioner because their doctor doesn't listen to them, the NP takes more time, cares more, is better than, etc".

*sorry for the grammar in this post, it's almost un-readable. Pre-coffee posting, everyone loses.

 

[NontradCA]

Reimbursement values are contracts between an entity (provider or hospital) and an insurance company. If a person's insurance through his work, has a preferred in-network provider as an NP, then the person will see the NP, or risk having to pay even more out of pocket, which he/she is not likely to do. The only thing stopping insurance companies from doing this is losing loads of customers which then decreases profit margins too much. That fear is what keeps this at bay.

Scope of practice is decided by state legislatures not hospitals or a group.

I think that people will choose whichever insurance lets them see a physician. I also think that insurance companies and legislatures have no incentive for paying NPs the same. That would make them lose money/physicians practicing in their states.

 

[NontradCA]

I'm not sure about this, my tongue is actually shorter now from all the biting than it was 3 years ago when I started paying attention to all the people who tell me they'd "rather see a Nurse Practitioner because their doctor doesn't listen to them, takes more time, cares more, is better than, etc".

I've never heard that out of a persons mouth in real life.

 

[DocVapor]

I've never heard that out of a persons mouth in real life.

Sadly, during my tenure in EMS, I heard it almost on a weekly basis.

 

[WhippleWhileWeWork]

I've never heard that out of a persons mouth in real life.

I'm actually quite glad to hear that.

 

[boogaloo]

I'll just say, I love Susie 2310:
I agree that the clinical importance of the physician's expertise is being underestimated. I am sure too that the cost-effectiveness of nurse practitioners is being over-estimated.

Nurse practitioner training at the master's level involves around 600 hours of clinical training or less according to the web sites of prominent universities I checked. This is but a fraction of the number of clinical hours of training a physician receives. A physician generally has a bachelor's degree in a science, attends medical school for four years, and spends several more years doing residencies, internships and fellowships. To train as a Nurse Practitioner one is required to be an RN, with a BSN, and NP schooling is generally three years.

There's no question whether or not physicians have more clinical training than NPs; the better question is, "Does it matter?" I don't think anybody will know the answer to that question until we're neck-deep in this power struggle. It's funny that we rag on NPs, but I've worked with MDs who have also been incompetent despite their rigorous training and thousands of hours spent learning medicine. I look at some of my classmates and see the same issue brewing. Some just want to scrape by in medical school, and they don't care if they barely pass Step I/II because P=MD, amirite? We brought this upon ourselves, and unless future "studies" show that NP care is inadequate (doubt it), then we're going to lose this battle regardless of how much training we've had under our belt.

My personal opinion is that NPs can be competent, but the rate at which the schools are churning them out will severely dilute the quality of NPs and eventually compromise patient care. I know someone who is in NP school doing their courses online. It's a f***ing joke. Furthermore, all of the nurses I personally know (and grew up with) weren't exactly the sharpest crayons in the box in high school or college. Heck, even the nursing students I got *ahem* really familiar with are, on average, not that smart. On the other hand, almost everybody at my medical school was, at the very least, above average in undergrad and would outperform 99% of the nursing students on standardized exams, so I guess we got that going for us. Personally, I don't feel threatened, but I do feel bad for the PCPs who put in all of this time and effort to be good physicians and have that be belittled by nurse practitioners who want a piece of the pie. "My name is Doctor So-and-so, DNP." Give me a break. Our only hope is that some measurable outcome will disprove the notion that NPs can provide adequate care without physician oversight, but I don't think it will happen.

 

[WhippleWhileWeWork]

My n=1 here, I know a NP who will soon be a DNP. Dude flunked biology 2 at a State U, which delayed his entering nursing school. He then takes it again, should be easy breezy the second time, right? No, dude has to grovel and beg for a C because he really earned a D which would have further delayed his nursing school entrance. Fast forward, he later gets his BSN online, his wife does several homework assignments for him (I saw it myself). He's just wrapping up his NP degree and will soon start his DNP program so that he can be a "Doctor" and practice on his own. I like the kid, but I wouldn't send my enemy to him for a health problem.

They say MDs don't want to allow NPs autonomy, why not? Money.
Why do nurses want to become NP/DNPs? Oh right, Money.

I say let them go crazy with autonomy. Just make sure physicians get the word out early and often that they are only giving the politicians and nurses what they've demanded and implemented themselves.

In fact, let's just go full on two tiered system.

 

[DermViser]

I think that people will choose whichever insurance lets them see a physician. I also think that insurance companies and legislatures have no incentive for paying NPs the same. That would make them lose money/physicians practicing in their states.

Well, it's not up to them. If Medicare does it, then private insurance follows.

 

[DermViser]

There's no question whether or not physicians have more clinical training than NPs; the better question is, "Does it matter?" I don't think anybody will know the answer to that question until we're neck-deep in this power struggle. It's funny that we rag on NPs, but I've worked with MDs who have also been incompetent despite their rigorous training and thousands of hours spent learning medicine. I look at some of my classmates and see the same issue brewing. Some just want to scrape by in medical school, and they don't care if they barely pass Step I/II because P=MD, amirite? We brought this upon ourselves, and unless future "studies" show that NP care is inadequate (doubt it), then we're going to lose this battle regardless of how much training we've had under our belt.

My personal opinion is that NPs can be competent, but the rate at which the schools are churning them out will severely dilute the quality of NPs and eventually compromise patient care. I know someone who is in NP school doing their courses online. It's a f***ing joke. Furthermore, all of the nurses I personally know (and grew up with) weren't exactly the sharpest crayons in the box in high school or college. Heck, even the nursing students I got *ahem* really familiar with are, on average, not that smart. On the other hand, almost everybody at my medical school was, at the very least, above average in undergrad and would outperform 99% of the nursing students on standardized exams, so I guess we got that going for us. Personally, I don't feel threatened, but I do feel bad for the PCPs who put in all of this time and effort to be good physicians and have that be belittled by nurse practitioners who want a piece of the pie. "My name is Doctor So-and-so, DNP." Give me a break. Our only hope is that some measurable outcome will disprove the notion that NPs can provide adequate care without physician oversight, but I don't think it will happen.

See her quote. As a nurse, when push came to shove for her and her family, she wanted a physician. That's the key here.

 

[NontradCA]

Well, it's not up to them. If Medicare does it, then private insurance follows.

There's also no incentive for Medicare to do this either. When NPs start demanding government pays them the same as physicians you'll quickly see the government say they're not equivalent to physicians.

And it certainly is up to a hospital how much to pay a salary. If NPs cost as much as physicians to hire, then there's no place for them at all, except in the most underserved of areas.

 

[postbacpremed87]

My n=1 here, I know a NP who will soon be a DNP. Dude flunked biology 2 at a State U, which delayed his entering nursing school. He then takes it again, should be easy breezy the second time, right? No, dude has to grovel and beg for a C because he really earned a D which would have further delayed his nursing school entrance. Fast forward, he later gets his BSN online, his wife does several homework assignments for him (I saw it myself). He's just wrapping up his NP degree and will soon start his DNP program so that he can be a "Doctor" and practice on his own. I like the kid, but I wouldn't send my enemy to him for a health problem.

They say MDs don't want to allow NPs autonomy, why not? Money.
Why do nurses want to become NP/DNPs? Oh right, Money.

I say let them go crazy with autonomy. Just make sure physicians get the word out early and often that they are only giving the politicians and nurses what they've demanded and implemented themselves.

In fact, let's just go full on two tiered system.

Give them independence, but also full responsibility for the outcome of their decisions and no collaboration with physicians because they will be in the role of "physician". They can consult other NP's if needed.

 

[Prodromo]

There's also no incentive for Medicare to do this either. When NPs start demanding government pays them the same as physicians you'll quickly see the government say they're not equivalent to physicians.

And it certainly is up to a hospital how much to pay a salary. If NPs cost as much as physicians to hire, then there's no place for them at all, except in the most underserved of areas.

I think you are being too optimistic. I think the government is more likely to lower PCP salaries to NP levels if the "equivalent" bs gets spread around enough.

 

[WhippleWhileWeWork]

Calling @JourneyAgent , where art thou?

 

[NontradCA]

I think you are being too optimistic. I think the government is more likely to lower PCP salaries to NP levels if the "equivalent" bs gets spread around enough.

They could if they want to see mass exodus.

 

[postbacpremed87]

I think you are being too optimistic. I think the government is more likely to lower PCP salaries to NP levels if the "equivalent" bs gets spread around enough.

They would no longer be PCP salaries at that point. They would be NP salaries because no physician would go into primary care.

 

[WhippleWhileWeWork]

They could if they want to see mass exodus.

Where would the newly minted PCPs go? 30 years old, just getting career off the ground in FM, salary just got cut down to a cool 110k. What can they do at that point?

Sure, current med students might detour maybe even some residents jump ship. But a few generations will be trapped.

 

[NontradCA]

Where would the newly minted PCPs go? 30 years old, just getting career off the ground in FM, salary just got cut down to a cool 110k. What can they do at that point?

Sure, current med students might detour maybe even some residents jump ship. But a few generations will be trapped.

It wouldn't happen for one, and I'm almost positive they'd go into other professions if it did.

 

[Nidor]

.

 

[WhippleWhileWeWork]

It wouldn't happen for one, and I'm almost positive they'd go into other professions if it did.

?? "They" in this context are already in the profession. Unless you mean they'd jump ship to be auto mechanics or landscapers?

 

[NontradCA]

?? "They" in this context are already in the profession. Unless you mean they'd jump ship to be auto mechanics or landscapers?

Yes, I could see that. Maybe pay off their debt first, but most would leave given the already low job satisfaction.

 

[WhippleWhileWeWork]

Yes, I could see that.

Ok so you're saying you think current PCPs or soon to be PCPs would mass exodus style leave the profession entirely and enter other low skill/low education barrier professions?
I was just trying to understand where you were saying this mass exodus would be to. "Where would they go?". I'm not trying to be confusing.

 

[DermViser]

Where would the newly minted PCPs go? 30 years old, just getting career off the ground in FM, salary just got cut down to a cool 110k. What can they do at that point?

Sure, current med students might detour maybe even some residents jump ship. But a few generations will be trapped.

The concierge medicine/direct pay model most likely. Good for them, IMHO.

 

[NontradCA]

Ok so you're saying you think current PCPs or soon to be PCPs would mass exodus style leave the profession entirely and enter other low skill/low education barrier professions?
I was just trying to understand where you were saying this mass exodus would be to. "Where would they go?". I'm not trying to be confusing.

Yes? Why would they continue to undertake increasing hours, high stress and responsibility. I'm just using logic here.

 

[Gifted Hands]

The average lay person doesn't know the difference between being seen by a NP or a MD/DO, just see the comments on that article for proof. Sure, the upper class will senna a physician, but the average joe just wants to be seen, they don't care by who.

If insurance companies decide they want to use NPs over MD practices, patients will go wherever it's cheaper unless they are of means.

 

[NontradCA]

The average lay person doesn't know the difference between being seen by a NP or a MD/DO, just see the comments on that article for proof. Sure, the upper class will senna a physician, but the average joe just wants to be seen, they don't care by who.

If insurance companies decide they want to use NPs over MD practices, patients will go wherever it's cheaper unless they are of means.

This is simply not true. I think that the main reason people see NPs or PAs is out of pure convenience. Most people trust a physician over a NP and know the difference.

 

[NontradCA]

I also think that you can't have a two tiered system without uproar. The AARP is the biggest lobby group in the country, and they are also the ones who require the most care. If insurances start telling people they have to see a NP v a physician, politicians will feel it.

 

[dadaddadaBATMAN]

I think the best thing we can do is gather in large groups, and stare at the sky while the storm that so many have predicted for so long gathers. When the rains begin to pour, we should collectively open our mouths like a rafter of turkeys (the actual term for a group I guess), and drown like good little physicians. Our collective last gasp should be something like "it's too bad that we couldn't do anything about this besides bitch about the unwashed masses."

Alternatively, we could talk to our friends and relatives, become educated about the research being used against us, write to our congressmen, and take part in the political process.

This seems more painful than drowning, so instead I'll move into a difficult to replace specialty and enjoy the show of gross incompetence. I'll also try to save my patients from our new colleagues general lack of education whenever I can, and very unprofessionally enjoy myself by telling their patients precisely what should have been done and wasn't. Or at least, I'll snicker to myself later and bitch to my wife about my co-workers. Like every other profession in the world.

 

[Nasrudin]

This is simply not true. I think that the main reason people see NPs or PAs is out of pure convenience. Most people trust a physician over a NP and know the difference.

You underestimate the power of the dark side, I'm afraid.

Their obedience to groupthink has a cult like power. Fools with the alluring ideas of class warfare in their heads are no match for this dark sorcery.

We [email protected] think, frankly.

 

[WhippleWhileWeWork]

I also think that you can't have a two tiered system without uproar. The AARP is the biggest lobby group in the country, and they are also the ones who require the most care. If insurances start telling people they have to see a NP v a physician, politicians will feel it.

That's exactly the point, put the screws to the b@stards that are ramming this down everyones' throats.

 

[DermViser]

So I thought this was quite interesting in the discussion:

http://www.kevinmd.com/blog/2014/05/time-doctors-doctors.html

 

[touchpause13]

So I thought this was quite interesting in the discussion:

http://www.kevinmd.com/blog/2014/05/time-doctors-doctors.html

Interesting.

He certainly has some points but I'm just not a fan of the doom and gloom.

 

[NontradCA]

You underestimate the power of the dark side, I'm afraid.

Their obedience to groupthink has a cult like power. Fools with the alluring ideas of class warfare in their heads are no match for this dark sorcery.

We [email protected] think, frankly.

I think you underestimate them actually. You can't have it both ways. The public knows physicians, evidenced by how evil they think they are, malpractice lawsuits etc. Just imagine how hard they would come down on nurses trying to take care of them. People feel they're entitled to care...do you really think they're going to be fine with NPs? Let's be real, you'll hear people refuse to see NPs or PAs a lot. Moreso than you'll hear them say they want an NP over a physician. Admit it.

 

[DermViser]

Interesting.

He certainly has some points but I'm just not a fan of the doom and gloom.

Well, as a psychiatrist in PP, you might be shielded from a lot of it.

 

[DermViser]

I think you underestimate them actually. You can't have it both ways. The public knows physicians, evidenced by how evil they think they are, malpractice lawsuits etc. Just imagine how hard they would come down on nurses trying to take care of them.

Except they hold up nurses to be Florence Nightingale who care and take the time to listen.

 

[NontradCA]

Except they hold up nurses to be Florence Nightingale who care and take the time to listen.

Yes, RNs. But they don't want them writing orders.

 

[DermViser]

Yes, RNs. But they don't want them writing orders.

Inpatient maybe not, outpatient is another story.

 

[NontradCA]

Inpatient maybe not, outpatient is another story.

Ok. But if they (patients) believe Nurses are equivalent to physicians then they will hold them to the same standard. I don't think Nurses want that.

 

[DermViser]

Ok. But if they (patients) believe Nurses are equivalent to physicians then they will hold them to the same standard. I don't think Nurses want that.

You're assuming patients value actual care. They don't They value the "soft" stuff - "she held my hand and was empathetic", "she let me talk about all my problems, without rushing me," etc.

 

[touchpause13]

Well, as a psychiatrist in PP, you might be shielded from a lot of it.

God I hope I will be.

 

[WhippleWhileWeWork]

I think you underestimate them actually. You can't have it both ways. The public knows physicians, evidenced by how evil they think they are, malpractice lawsuits etc. Just imagine how hard they would come down on nurses trying to take care of them. People feel they're entitled to care...do you really think they're going to be fine with NPs? Let's be real, you'll hear people refuse to see NPs or PAs a lot. Moreso than you'll hear them say they want an NP over a physician. Admit it.

You share your opinion as if it's a fact. You seem to confuse what you know with what you believe.
Differing opinions are what make this place interesting, no need to try and make everyone conform to yours.