RNs writing prescriptions?
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some provides (a bit on the lazy side) allow their rn to "pre write" or they actually "pre sign" script.
not very legal or ethical--but when you have to write 50 freakin scripts per day it can infact be helpful.
not very legal or ethical--but when you have to write 50 freakin scripts per day it can infact be helpful.
No, I don't mean that. For that matter, I'm an MS3 and I do that. I meant actually writing and signing the prescription, and having their name on the bottle .
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Yes its BS and as usual its doctors who are opening the floodgates to everybody and their brother writing scripts.
WHORING OF THE MEDICAL PROFESSION PART 100
It starts out small and simple. Who would it hurt? I see about 30 patients per day. If I let my RN write scripts for me and see patietns on her own, I could see at least 10 more patients per day and make a lot more money. Lets do it.
(Fast forward 6 months)....
I make 300 thou a year, get to buy a lot of beer. Things are goin great, and they're only gettin better.....my future's so bright I gotta wear shades.
(Fast forward 2 years)....
Wow this thing has really blown up. I used to be the only doc who did this, but my colleagues have quickly caught on and now they all have their RNs see patients and write scripts so they can make more money. Of course we sign all the charts at hte end of the day.
(Fast forward another 2 years).....
Who the hell do these nurses think they are? They think they should be allowed to work independently and write their own scripts? Since I heard about this new legislation I am furious. I will testify before my state legislature to prevent this nonsense.
(State legislature)....
Senator: Dr, how do you feel about nurses being granted independent script rights?
Dr: I strongly oppose it. They are not trained to do medicine. They dont understand pharmacology. They are not doctors and should not be given this privilege.
Senator: Dr, isnt it true that RNs write most of the scripts at your clinic?
Dr: Yes, but uhhh
Senator: Isnt it also true that you only review cases at hte ned of the day, or in some cases at the end of the week, in such a fashion that the patient's management and treatment at the point of care is managed almost exclusively by nurses?
Dr: No, i always cosign charts
Senator: But only AFTER the patient has left hte clinic, correct? Isnt it true that you only sign charts at the end of the day? Isnt it true that some of your colleagues in fact dont cosign charts until months later?
Dr: I dont know what my colleagues are doing
Senator: We do, Dr. You see, while you were running your little operation makeing 300 thou a year and wearing shades, the nurses in your employment were gathering data. They were gathering data showing that their outcomes were in fact similar to yours, Dr, with almost no oversight and the ability to virtually operate independently.
Healthcare in this state is a fundamental right. Since you obviously trust nurses so much that you let them oeprate independently in your clinic, the legislature has made the determination that they should be granted formal independence. After all, the doctors have voted with their actions. Everywhere the legislature looks, we see RNs writing scripts in virtual independent authority from doctors. Since doctors obviously trust this system, why shouldnt the general public?
Dr: Hey i never...
Senator: You never what? Thought that nurses should operate independently? Thats not what your clinical practice shows. Your clinical practice shows that in fact you do believe they can work independently with no oversight. Dont con us, doctor. We know what went on in your clinic.
(6 months after state legislature passes laws giving independent script rights to RNs)
Well the party's over here folks. I used to make 300 thou a year, but lately the insurance secotr has decided that they are going to reimburse us at the same rate as RNs. Several new RN-only clinics have opened up, and my patient base is dwindling. Fortunately we are the only state htat operates this way, so I can just move over a state and start another practice.
(6 months later)
OK in my new state now, back to making 300 thou a year. I still have RNs writing scripts, but the state laws are different so I'm protected from any turf wars.
(6 months later, doctor gets a notice that state legislature is contemplating a virtually identical bill)
Oh no, here we go again.
Senator: Doctor how do you feel about this proposed legislation?
Dr: Obviously a travesty in the making senator. Nurses are not capable of managing patients.
Senator: Thats not what the data in state X show. Since the law has changed there, no data indicates any difference in clinical outcomes between independent RNs and doctors. We feel the legislation in state X is a good model for other states. They have opened the door, and healthcare costs are very high. Since healthcare is a fundamental right, the legislature will follow state X in tehir implementation of this bold and initiative strategy to ensure that all the people of this great state have access to medical care.
Dr: Oh ****, there goes the planet
WHORING OF THE MEDICAL PROFESSION PART 100
It starts out small and simple. Who would it hurt? I see about 30 patients per day. If I let my RN write scripts for me and see patietns on her own, I could see at least 10 more patients per day and make a lot more money. Lets do it.
(Fast forward 6 months)....
I make 300 thou a year, get to buy a lot of beer. Things are goin great, and they're only gettin better.....my future's so bright I gotta wear shades.
(Fast forward 2 years)....
Wow this thing has really blown up. I used to be the only doc who did this, but my colleagues have quickly caught on and now they all have their RNs see patients and write scripts so they can make more money. Of course we sign all the charts at hte end of the day.
(Fast forward another 2 years).....
Who the hell do these nurses think they are? They think they should be allowed to work independently and write their own scripts? Since I heard about this new legislation I am furious. I will testify before my state legislature to prevent this nonsense.
(State legislature)....
Senator: Dr, how do you feel about nurses being granted independent script rights?
Dr: I strongly oppose it. They are not trained to do medicine. They dont understand pharmacology. They are not doctors and should not be given this privilege.
Senator: Dr, isnt it true that RNs write most of the scripts at your clinic?
Dr: Yes, but uhhh
Senator: Isnt it also true that you only review cases at hte ned of the day, or in some cases at the end of the week, in such a fashion that the patient's management and treatment at the point of care is managed almost exclusively by nurses?
Dr: No, i always cosign charts
Senator: But only AFTER the patient has left hte clinic, correct? Isnt it true that you only sign charts at the end of the day? Isnt it true that some of your colleagues in fact dont cosign charts until months later?
Dr: I dont know what my colleagues are doing
Senator: We do, Dr. You see, while you were running your little operation makeing 300 thou a year and wearing shades, the nurses in your employment were gathering data. They were gathering data showing that their outcomes were in fact similar to yours, Dr, with almost no oversight and the ability to virtually operate independently.
Healthcare in this state is a fundamental right. Since you obviously trust nurses so much that you let them oeprate independently in your clinic, the legislature has made the determination that they should be granted formal independence. After all, the doctors have voted with their actions. Everywhere the legislature looks, we see RNs writing scripts in virtual independent authority from doctors. Since doctors obviously trust this system, why shouldnt the general public?
Dr: Hey i never...
Senator: You never what? Thought that nurses should operate independently? Thats not what your clinical practice shows. Your clinical practice shows that in fact you do believe they can work independently with no oversight. Dont con us, doctor. We know what went on in your clinic.
(6 months after state legislature passes laws giving independent script rights to RNs)
Well the party's over here folks. I used to make 300 thou a year, but lately the insurance secotr has decided that they are going to reimburse us at the same rate as RNs. Several new RN-only clinics have opened up, and my patient base is dwindling. Fortunately we are the only state htat operates this way, so I can just move over a state and start another practice.
(6 months later)
OK in my new state now, back to making 300 thou a year. I still have RNs writing scripts, but the state laws are different so I'm protected from any turf wars.
(6 months later, doctor gets a notice that state legislature is contemplating a virtually identical bill)
Oh no, here we go again.
Senator: Doctor how do you feel about this proposed legislation?
Dr: Obviously a travesty in the making senator. Nurses are not capable of managing patients.
Senator: Thats not what the data in state X show. Since the law has changed there, no data indicates any difference in clinical outcomes between independent RNs and doctors. We feel the legislation in state X is a good model for other states. They have opened the door, and healthcare costs are very high. Since healthcare is a fundamental right, the legislature will follow state X in tehir implementation of this bold and initiative strategy to ensure that all the people of this great state have access to medical care.
Dr: Oh ****, there goes the planet
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BTW, for those who dont want to read my long winded rant above, my basic point is that there has NEVER been any midlevel encroachment that did not start with doctors giving away the keys to the kingdom.
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haha i was gonna say thats one long conversation to yourself.
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Hey, if it can be shown that there is no difference in clinical outcome, I have no problem with RNs writing prescriptions for me as a patient. With the same evidence, I would let a janitor perform open heart surgery on me with a plastic spoon.
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It's a deal.
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Are you sure they're not NPs? That the doc's name does not appear on the rx? Because if they are truly writing scripts on their own, that's a violation of the nurse practice act in every state. You lose your license for that.
I'm sure. Does it matter that it's just Retin-A? The only name on the script is "Jane Doe, RN".
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Correct me if I am wrong.... As far as I know.... If some insurance company notes this...... that physician will sooner or later get his/her license revoked and the pharmacist who is filling the prescription might get in trouble when getting audited.... not to mention the nurse herself.
That's why I was asking if there was a new law about RN's being able to write now. This is in FL by the way. Can't find anything on the web.
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'Regular' RNs don't have prescriptive authority anywhere that I've seen. The nurse you're speaking of must be an APRN of some sort--you should double check and make sure you're understanding the situation completely...obviously if it's truly a non-AP several heads would roll--RN and RPh at a minimum.
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Picked up an RX from my primary awhile back and got half way to my car and realized it didn't have the DEA number on it. I can tell the difference in handwriting on the drug, and the MD's on the signature so it makes you think something like that happened.
Maybe. All I saw was my gf's tube of Retin-A, and it says "Jane Doe, RN".
M
Mr. McDuck
Do you know the nurse? I know a few NPs that put RN after their name instead of NP or whatever else they can put. Maybe she is an NP and just put RN.
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The prescriptive authority is granted by each state...so, again, there are 50 variations on this......but in CA,yes - RN's can be given prescriptive authority if they are functioning under a collaborative practice agreement which has been authorized by the state.
In my state, there are a few of these, but not many. Again, in my state, most NP's will just use RN after their name, not NP. Locally, we know who these are, so we aren't just filliing rxs blindly - that's part of our job - to make sure we are filling a valid rx which is appropriate for the pt. If you took that rx out of the area, it probably wouldn't be filled readily. RNs, med assistants, receptionists write out rxs all the time & have it signed by the prescriber - we are used to our local prescribers & what they write. If something funny comes up, we call - usually at a time when the office staff is gone & we can talk to the prescriber so we know an office staff person is not using your identity to write or call in fake rxs. If this has happened to you, you might have perceived it as bothersome since we are calling "after hours", but that is how we pick up fake rxs from office personnel - which is often who is using your identity.
The DEA # is a midlevel number which has different letters preceding the DEA than MD/DO, DDS/DMD.
The name & title you see on the rx bottle is just a reflection of what we as pharmacists put in the prescriber field. For example...your name could be:
J.T. Franklin Peter Jones, MD, PhD, MPH; but, I'll likely just enter your name in my computer as Frank Jones, MD.
Likewise, if you have a very long name, your first name or title may be deleted because there just aren't enough characters.
Just a function of computer programming.
Its personal habit of pharmacists if we use the RN's name or the covering physician of the collaborative practice agreement - either way is legal. In my own case, I can prescribe & dispense Plan B under a collaborative practice agreement of a physician from 3 counties over - I use my name on the rx label.
Hope that clarifies a bit!
In my state, there are a few of these, but not many. Again, in my state, most NP's will just use RN after their name, not NP. Locally, we know who these are, so we aren't just filliing rxs blindly - that's part of our job - to make sure we are filling a valid rx which is appropriate for the pt. If you took that rx out of the area, it probably wouldn't be filled readily. RNs, med assistants, receptionists write out rxs all the time & have it signed by the prescriber - we are used to our local prescribers & what they write. If something funny comes up, we call - usually at a time when the office staff is gone & we can talk to the prescriber so we know an office staff person is not using your identity to write or call in fake rxs. If this has happened to you, you might have perceived it as bothersome since we are calling "after hours", but that is how we pick up fake rxs from office personnel - which is often who is using your identity.
The DEA # is a midlevel number which has different letters preceding the DEA than MD/DO, DDS/DMD.
The name & title you see on the rx bottle is just a reflection of what we as pharmacists put in the prescriber field. For example...your name could be:
J.T. Franklin Peter Jones, MD, PhD, MPH; but, I'll likely just enter your name in my computer as Frank Jones, MD.
Likewise, if you have a very long name, your first name or title may be deleted because there just aren't enough characters.
Just a function of computer programming.
Its personal habit of pharmacists if we use the RN's name or the covering physician of the collaborative practice agreement - either way is legal. In my own case, I can prescribe & dispense Plan B under a collaborative practice agreement of a physician from 3 counties over - I use my name on the rx label.
Hope that clarifies a bit!
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Uhm - in this scenario, the nurses gathered evidence and the evidence supports equal outcomes, equal safety, increased efficiency, and cost-effectiveness of the plan, so what is the problem?
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MD gets nothing for each rx - as you get nothing for each rx you write. Thats called a kickback & is illegal in all states.
The MD agrees to it to allow for greater access to Plan B (in the case I gave as an example). He is a Planned Parenthood MD & actually most Planned Parenthood MD's will agree to a collaborative practice agreement for Plan B in my state. The particular individual is just in the Planned Parenthood which is closest to my corporate headquarters & he signed the agreement for all the pharmacists in my corporation....nothing subversive about it.
As for other collaborative practice arrangements - the nurses are employed by large clinic practices which see things like well child checks. They write Fl rxs or vits w/Fl - the dose is by pts age. Or they are in anticoagulation clinics of group practices & dose warfarin by the INR.....if this INR, then that dose change....very basic.
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NPs, PAs, XXX who cares. Stop selling yourself. The only person who should be doing the doctor work is the doctor.
I asked a pharm intern about it, and he said that at his CVS they just put NP's in as "RN". So I guess that explains it.
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I strongly agree.
By the way, what do you guys think about those articles:
www.webmd.com/content/article/18/1685_53050.htm
http://archives.cnn.com/2000/HEALTH/01/05/nurses.vs.doctors/
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You mean my 4 yrs of training to get a Chemistry degree(to get into medical school mind you), 4 yrs of medical school, and 4 yrs of residency were pretty useless huh?
Nice.
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I thought it ended a little differently...
(10 years later, on a beach in St. Croix...)
Old Dr: Man, I'm so smart. Thanks to my brilliant idea to farm out prescriptions to RNs, I was able to make $300k a year and now I'm loving retirement. Mmm, this pinacolada is delicious. Think I'll go for a sail.
Freshly minted young doc fresh out of residency: Hey! Thanks to these RNs having independent practice rights, I'm barely clearing $100k!
Old doc: Sucks to be you!
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Exactly.
Some of those old docs are still around and formulating opinions. I've go a few for them.
D
deleted4401
I'm not sure I understand the major issue. If the outcomes are the same, why piss and moan about it? It's all about patient care and outcomes.
I guess making less money is individually unsettling for physicans, but it's about access, availabilty, and quality. If the first two increase without a resultant decrease in the third, what's the problem?
I just don't see the need to protect ourselves from this. As in the business world, if there is an equal but cheaper alternative, it's up to the more expensive alternative to either: 1) provide a better product 2) decrease prices. It's simple enough.
But it's not necessarily bad, always. IR used to place pigtail catheters to drain ascites. Now the PA does it (it's pretty brainless, low margin work), and the IR doc can focus on more pressing, urgent, and profitable issues, such as draining a sigmoid abcess. There are so many other situations like this (i.e. letting the CRNA handle elective colonoscopies, and the anesthesiologist handle the liver transplant; letting the IM doc do the stress tests, and the cardiologist do the cath; letting the family doc do the flex sigs, and the GI doc do the colons).
A smart physician will see that although her slice is getting smaller, the pie is getting bigger. There is too much disease out there, and not enough provision. Someone has to provide the care, and whatever their training or degrees are, as long as the care is as good as a physician, there is no need for patients to worry. If outcomes are worse, that's when there will be an uproar and an outrage.
The sky is not falling. I promise.
-S
I guess making less money is individually unsettling for physicans, but it's about access, availabilty, and quality. If the first two increase without a resultant decrease in the third, what's the problem?
I just don't see the need to protect ourselves from this. As in the business world, if there is an equal but cheaper alternative, it's up to the more expensive alternative to either: 1) provide a better product 2) decrease prices. It's simple enough.
But it's not necessarily bad, always. IR used to place pigtail catheters to drain ascites. Now the PA does it (it's pretty brainless, low margin work), and the IR doc can focus on more pressing, urgent, and profitable issues, such as draining a sigmoid abcess. There are so many other situations like this (i.e. letting the CRNA handle elective colonoscopies, and the anesthesiologist handle the liver transplant; letting the IM doc do the stress tests, and the cardiologist do the cath; letting the family doc do the flex sigs, and the GI doc do the colons).
A smart physician will see that although her slice is getting smaller, the pie is getting bigger. There is too much disease out there, and not enough provision. Someone has to provide the care, and whatever their training or degrees are, as long as the care is as good as a physician, there is no need for patients to worry. If outcomes are worse, that's when there will be an uproar and an outrage.
The sky is not falling. I promise.
-S
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Thats all fine and good in a medical system that pays for anything and everything with no questions asked.
But if the US goes socialized (and it will eventually) this world view is going to come crashing to a halt because socialized medicine wont pay for all the fancy techno stuff we utilize routinely here in the US. When that happens, doctors will be competing with nurses, crnas, and others for the "bread and butter" stuff that Medicare will actually pay for.
Interventional radiology as we know it in the USA does not exist in Europe because their socialized models wont pay for fancy techno stuff that has very minimal outcomes benefit.
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So let me get this straight. The MD gets no money for participating in this "collaborative" relationship. However, if there pharmacist makes a mistake, I can guarantee you the MD is going to be named in the suit along with the pharmacist. So basically the MD is taking a huge risk for no gain.
I'll ask again. Why would an MD want to do this?
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In a free market business world ----- Maybe...
But in the US... the physician payment is DETERMINED by the amount medicare/medicaid pays... go ask any insurance company and they will tell you that's how they base how much they pay physicians....
Of course medicare/medicaid has their own issues.
So INDIRECTLY the market is goverment controlled...
Second... the physicians are not allowed to have self interest practices unlike a free market. What do I mean? Pathologists can't own the labs they send their slices to get stained because they dont want the pathologists to order a lot of tests that will make em richer from their own labs... this is not true in the real market... I wouldn't be surprised that in the future they disallow cardiologists from owning their own echo machines so that they dont order them unnecessarily.
Third... doctors aren't allowed to unionize... you wont see all cardiologists unionize so they can't push back for better benefits etc etc. They can't unionize to get better lawsuit protection... etc etc.
Fourth... in this business you can't refuse service... Have you ever heard of a free market business that can't refuse to do business? ESPECIALLY poor general surgeons who can't refuse emergency service in the ER. Can't refuse that emergency appendectomy even though it is more work and pays less than placing a mediport.
So now that we established that the rules are no where near free market... it is within the best interest of this country to protect the medical system else it will collapse.
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Not sure I understand exactly what mistake could happen...
For a well-child check...which the MD has previously done, btw...the RN is clear to write the rx for Tri-Vi-Flor according to pts age & wt.
For Plan B...the woman comes in & requests emergency contraception. Fills out a questionairre & if all answers fall within the appropriate yes/no & date categories...she gets Plan B - dose is the same for all women. (Fortunately...going otc so shouldn't be an issue for long...)
For anticoag....the MD/DO group has specified the parameters of when & how the dose is to be changed based on specific fingerstick parameters & questions (yes/no answers). If anything is "gray" the pt is referred to their MD/DO for dose adjustment, otherwise it is according to the prearranged scale.
This is similar to K-scale, heparin & Mg/Ca standing orders in hospitals.
Do you really want to be called for all that routine stuff? If so...just don't participate in collaborative practice agreements.
Other MD/DO's don't feel that way & feel comfortable with the "standing" orders they have or collaborative practice agreements which are in place.
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There is not one state where this is legal. That person HAD to have been a nurse practitioner. Maybe she was too lazy to list all those letters after her name, so she just wrote RN.
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All nurse practitioners are also RN's. I would immediately go to the pharmacy that filled the script and demand to know if the person has a prescribing #/DEA number. They HAVE to in order to write prescriptions, no matter what the drug and they HAVE to be a nurse practitioner.
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Docs in primary care will become obsolete in a few years. I read somewhere that the VA replaced most docs with NP's at their outpatient clinics years ago. They even did a study a few years back that showed clinical outcomes were actually BETTER when the patients were treated by NP's. My nephew is a second year med student and they were told to become specialists, otherwise they would have a difficult time finding a job. Also, my friend (anesthesiologist) convinced his son to go to NURSING SCHOOL and then on to a nurse anesthetist program. I almost had a MI, but the reasoning (less responsibility, 150K/yr, less time/$$$ in school, etc) is sound.
It's only a matter of time before Medicare and insurance companies demand patients see NP's, since their reimbursement is less. The NP's have all those positive studies to back them up, so docs are screwed. Something else to worry about, NP's are now "specializing" in medical fields (read anesthesia). There are psychiatric NP's, neonatal NP's, geriatric NP's, the list goes on and on. Dont' be surprised if the primary care NP starts referring patients to the psych NP's, etc. Medicine ain't what it used to be.
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Then why are medical schools promoting the idea of primary care so heavily and acting desperate for students who want to go into it?
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Because most people are aware that PCP's are being replaced with midlevels and medical students are steering clear of the field. I know of a large physician owned clinic who replaced all their family practice docs with midlevels, simply to generate more money. Remember, a midlevel can bill at the doctor rate when at least one physician is present in the building, so they generate the same amount of money as the doc, but are paid much less! Midlevels are dragging down the salaries and it's only going to get worse.
D
deleted87716
No, they're not.
No, they're not.
You can keep repeating crap that you heard somewhere else on SDN, but that doesn't make it true.
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You misunderstood my question. If there is no future for doctors in primary care, why do medical schools want their graduates to go into primary care?
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No they don't - they only need a DEA # if they want to prescribe controlled drugs & if they want to have insurance billed (which will become a nonissue in May 2007). After May 2007 - the DEA# will only be needed if a controlled substance is prescribed.
If they have a midlevel DEA #, that means they are functioning under a collaborative practice agreement or as an employee of a physician &/or prescriber group who delineates the scope & extent of how they practice & oversees such practice.
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In CA its legal. We have certified nurse midwives who are not NP's who have prescriptive authority. They just use RN.
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