Should physicians let NP/PA take over primary care and anesthesia?

Discussion in 'Topics in Healthcare' started by BestDoctorEver, Aug 31, 2014.

  1. SDN is made possible through member donations, sponsorships, and our volunteers. Learn about SDN's nonprofit mission.
  1. Smurfette

    Smurfette The blonde among the blue. SDN Administrator 10+ Year Member

    3,945
    1,512
    Jun 6, 2001
    Physician
    Since this is not really relevant to medical students so much as the medical system in general, moving to TIH.
     
  2. SDN Members don't see this ad. About the ads.
  3. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    No NPs right out of school I know practices independently - especially in a setting like Kaiser. No employer will allow for an NP to practice independently right out of school. Trust me, you wont be able to get that type of pool that you are asking for (i.e., new grad NPs practicing independently right out of school). The studies that show equivalency in practice are head-to-head studies with experienced NPs and physicians in primary care and urgent care type settings.

    Let me ask you, in a study like this would you be able to control for the one-million confounding variables that are going to crop up over a ten year study like this? A study like this I would imagine have lots of holes in it. And the funding? Do you think you would get IRB approval? How about consent from the NPs, physicians, and patient's participating in the study? Will you have a large enough sample size? Can you guarantee continuity of care?

    Last point - lets just say that you do make this study happen, are you suggesting that we pull all the NPs that are currently practicing with autonomy until the results of this said study are posted? If you do think that, and in theory it did happen, how do you think that would impact access to medical services and wait times, and work load of physicians, etc.? A lot of things to consider here.
     
    Last edited: Aug 11, 2017
  4. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    But if you have reached the end of your training, and your training is adequate, you should be able to do your job, no? Or are you admitting your training is inadequate?

    And you wouldn't need to fund it- Kaiser collect a bajillion data points on every provider. They'd merely have to wait and then compile the results at the end. As to confounding, over a patient population that is literally 400,000 individuals in size, there is unlikely to be much of it so long as the physicians and nurses are working in the same area, but that is why one does the study and looks for anomalies in the results. All they have to do is hire people, that's it. Don't even need to have the stipulation about physician backup- I'm confident enough to say that NPs will fail recognizing that they need backup often enough to make a statistical difference over a long enough period of time. Because it is practice as usual, yes an IRB would approve it. And I view NPs as like a drug the FDA pushed out too fast- it's considered safe until we get long-term data that shows it was actually a horrific mistake, at which point we pull it from the market. Once harm can be demonstrated, then we can start dialing things back.
     
  5. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    And I don't believe NPs should be stopped from practicing, I believe they should not be practicing independently. They are not qualified to do so unless they can prove otherwise, which they haven't. The studies to date have panels that are so small that they basically could cover a single NP's practice. To generalize the study to all NPs, you'd need somewhere around the mid 500s in number, and analyze their entire practices for a period of at least 10 years. Current studies suffer from serious length time bias, as it is the harm is likely to be insignificant over the short term and not show up until long-term damage is done or small mistakes start to pop up more frequently. I want to quantify the failure rate of NPs as compared to physicians over a long period of time. If it is nonexistent, then feel free to practice independently to your hearts' content.
     
    GrignardsReagent likes this.
  6. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    NP training is good training, but because we lack residency, no employers would ever hire NPs to practice independently right out school. I talked about this before so I feel like we're sort of going in circles on this point. Doesn't mean that the training is inadequate. Means that the pathway to independence is different. Regarding you study idea and how data will be collected, the VA already does this. So far the data shows they are safe. They compile data and measure competency and safety of their NP providers. I believe they've been doing this since 1990. Actually the VA is increasing scope even further for NPs. Probably in response to when they had some 25 sentinel events mainly d/t delays in treatments they moved forward with this.
     
    Last edited: Aug 11, 2017
  7. anbuitachi

    anbuitachi ASA Member 7+ Year Member

    2,573
    489
    Oct 26, 2008
    Utah
    I think NP can cover areas in shortage independently, but they should do further training similar to a residency. They can cover basic things like HTN and diabetes management etc. It's better than nothing in rural areas. CRNAs are more questionable. Managing HTN and diabetes and common primary care problems is less dangerous than managing patients intra op. One wrong move and the patient can die. However, CRNAs do do training before graduating, and can mostly handle basic ambulatory healthy cases. However the issue i have w CRNAs is that there is a HUGE variation in quality of graduated CRNAs. Some are great and some are worse than a first year anesthesia resident 6 month in. CRNA school is simply not regulated enough. Primary care is not a field where seconds count, so even if you dont know you can look it up on various reputable sites. That's often not the case in anesthesiology
     
    FNP_Blix likes this.
  8. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    Yeah, because the VA has such a focus on actually providing quality care :rolleyes: They have never published a study of their data on nurse practitioners, and have never made any statements about said data. The VA is also not the optimum environment for such a study, as it has a very specific patient population (veterans) and would not be generalizable. I'd still love for them to make the data available for analysis though. Oh wait... Nevermind. Their NPs didn't get independent practice until last year so it wouldn't be valid since they were under physician supervision and auditing per VA policy.

    As to "a different path to independence," uh, you are fully licensed to practice independently right out of school. That IS your path to independence, and there's more than one NP in my area that's opened up a clinic directly after graduating from the local Direct Entry Nurse Practitioner program, so don't even feed me that line of crap.
     
  9. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    Well then lets see how they do. To me thats very bold to go into solo practice right out of school. I personally wouldn't do it and the vast majority of NPs wouldn't. Wonder how they're doing nevertheless.

    And im sure that data is available somewhere, I will look for it when my plane lands. But even for solo NP or physician, you still ask questions, inquirie with colleagues, and make referrals. So dont know what you want here. Auditing still would take place for solo practitioner of their performance to ensure no harm. No one is ever truly practicing independently.
     
    Last edited: Aug 11, 2017
  10. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    FYI, using the VA as an example of good care equivalence is laughable. A witch doctor could provide equivalent care to many VA "providers".


    --
    Il Destriero
     
    Mad Jack likes this.
  11. MBVT

    MBVT

    14
    3
    Jul 5, 2017
    As a patient I am OK with a PA or NP when I know what the problem is and it is relatively simple or if they are acting on what a physician has directed be done. For example I had surgery on a finger earlier this year and then subsequently a PA took the stitches out. Another time I was concerned I might have lyme disease and it was a PA that looked at my arm and ordered a lyme disease test. NP's administered all of my bladder cancer treatments that my urologic oncologist ordered. Another time an NP lanced, drained, and froze a ganglion cyst based on her own assessment of what I had.

    Conversely in response to sporadic light headedness I saw my primary care physician and my cardiologist because I didn't know what the issue was and I wanted their level of education and expertise trying to figure out what was wrong. Same with chest pains and a lingering cough. Only physicians when what's wrong is not clear and is potentially serious.

    What I have not resolved for myself is whether I would go to a PA or NP for a routine annual physical. I haven't done it yet and wonder if they might miss something that a physician would have caught.
     
  12. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    All bantor aside, for a routine physical either is fine. Both PAs and NPs are great providers for the things you described in your experience as well.
     
  13. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    Thats really too bad they have such a bad reputation. Anyway, they've had their fair share of issues and its not reflective of NPs or their nursing staff as you just made it sound. Its access to medical care thats a major issue with them causing delays in treatment. But we're not debating VA stuff right now so...
     
  14. tymont12

    tymont12 But it can't be two illnesses! 5+ Year Member

    339
    455
    Jun 28, 2011
    The problem though, is that you are approaching your own health from a position of understanding what is potentially going on. The average patient may not care or know what the hell is going on, or who to go to for that matter.
     
  15. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    Have you been to a VA? There are a lot more problems than just access and treatment delays. They wish it was just access.
    (Though there are some high quality VAs that are at least partially staffed by university faculty.)


    --
    Il Destriero
     
  16. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    No cant say that I have. Thats too bad :-/
     
  17. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    A good physical can be the difference between finding something early or late.
    Knowing the difference between this:
    [​IMG]
    This:
    [​IMG]
    This:
    [​IMG]
    This:
    [​IMG]
    and this
    [​IMG]
    can save a patient's life. I'm not telling you which will kill your patient, but it's most of them in one way or another. That's just the eye, and a small sample. Don't trust a physical exam to a hack unless you actually don't care about your health.
     
  18. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    Calling NPs hacks wasn't very nice Mad Jack :-( You hurt my feelings. 1st image looks like aniridia, 2nd looks like PAM, 3rd looks like melanoma, 4th one looks normal to me but would need retroillumination to see iris transillumination defects and 5th one, not sure what I'm looking at..Contrary to what you think, I know that if you spot a primary acquired melanosis it can potentially lead to a malignant melanoma which both require referral to ophthalmologist.

    At the end of the day, you know that anytime the patient complains of severe and sudden vision loss or sudden severe non-traumatic eye pain or if physical exam reveals things like irregular pupil, hazy cornea, suspected herpes zoster ophthalmicus, corneal ulceration, limbal flush, muscle paresis, elevation of fundus on funduscopic exam, patient is seeing flashy lights (the list goes on) then those complaints or findings on exam should all lead to referral.

    I (nor should any primary care provider) should not even be messing with the eye unless for management of basically just conjunctivitis, keratitis sicca, hordeolum, blepharitis, and if you have the means to administer parenteral antibiotics, periorbital cellulitis. Can't think of a whole lot of anything else I would be managing in the office..
     
    Last edited: Aug 11, 2017
  19. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    Incredibly wrong on all but one count. You saved our melanoma patient, but our poor third patient develops dystonia and ataxia, and begins to hallucinate. Your first patient wonders how they can have aniridia if they've had perfect eye exams their whole life and never sees you again. Your fourth patient also has this on exam
    [​IMG]
    While your fifth says her father has some eye issues and wonders if she should see a specialist or if she is fine. Wut do?

    A physical exam is about taking a thorough inventory of a patient. This is all basic board material for physicians, I want to see how well you do by providing you with textbook cases that are of the sort that most medical students can answer them easily. You're failed 2/3 attempts so far, let's see how you do with more information.
     
    Staphylococcus Aureus likes this.
  20. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    The thing you're missing is that only one of these is an eye problem. One of them is a fatal or disabling condition that can easily be fixed and is often first noticed in the eye by primary care physicians, and is a patient that will never develop eye-related complaints. Once symptoms appear, they are irreversible. It isn't the job of a doctor to just notice things your patient is pointing out to you.

    And I never called NPs hacks. I said doubt trust your physical exam to a hack. That includes basically anyone that won't or can't do a proper physical exam.
     
  21. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    Okay the 3rd image is the melanoma patient. You mean the 2nd image? (if that one is not melanosis) this patient may be taking chlorpromazine which probably explains the dystonia and ataxia, and would be one explanation for the brown spot on her sclera, but I'd find out doing a thorough history to see what meds she taking, or if she's consumed any metals..The 4th one with the cafe au lait - are there a lot of these spots and is the patient experiencing any vision loss? May be NF. But still, I hold that that eye looks normal and would need retroillumination to deterimine iris transillumination defects if she is having symptoms..The 5th one, while I don't know what I'm looking at here (eye appears normal), I'd def. have her follow ophthalmologist, again if she is experiencing any changes in visual acuity, has diplopia, photophobia, etc. and especially given her family history. Is the 1st one glaucoma? Are his/her pupils reactive to light? How's that patient's vision? Any pain? Vomiting, headaches? Halos and lights? ...Not really sure what I'd call that in the 1st image, but I would def. do a thorough history and physical here and refer this patient to ophthalmologist.

    Again in general, any acute changes in vision, pain in the eye, irregular borders, or outside of the common conditions differential list that can be treated in the office, I'm referring them out always.
     
    Last edited: Aug 12, 2017
  22. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    NF, congrats, you're two for four, but you've failed the fifth patient and the health care system by referring her to a specialist and not asking about her father's eye condition (he's colorblind)- this is why many of the specialists I know refuse to take consults from NPs. As to our other patient, they are 22, were otherwise healthy prior to the onset of new symptoms, take no medications and are otherwise asymptomatic.
     
  23. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    Oh, and patient one is completely asymptomatic, healthy, 22, and female
     
  24. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    Okay well it could be benign (nevus), could be excessive exposure to sun, the patient may be pregnant which could darken the sclera, or underlying hemorrhage. Those are my best guesses. And I would have asked about what her father's history is - that is part of basic history taking. Don't think that a referral to ophthalmologist would be "failing the patient" or the healthcare system. If anything, it shows that I'm a safe provider, know my limits, and frankly it would be negligent to not refer a patient for something I'm not sure what it is. And funny, most physicians I know would and should take consults from NPs if they care at all about the population and their patients. Would you as a psychiatrist not refer a patient where melanosis or malignant melanoma should be ruled out? How can you say for sure that that brown spot is not melanosis without further testing from a specialist who is an expert in eyes? It's best practice to refer patient's for all the reasons I stated above.
     
    Last edited: Aug 12, 2017
  25. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    Appropriate referrals are fine. Inappropriate referrals waste valuable time and resources. Not being able to make a basic diagnosis leads to wasted time and money for everyone involved.
     
  26. MBVT

    MBVT

    14
    3
    Jul 5, 2017
    Yes I do go about it from a position of understanding having had my share of medical issues and from having observed family members navigate the medical system. Don't get me wrong, I do not try to self-diagnose but rather recognize what is doctor stuff vs what is OK for a PA or NP to do.

    On the matter of physicals, my current primary care physician is in practice for himself and does not have any staff other than a receptionist/billing clerk that he shares with another medical provider, so the matter of a PA or NP doing a physical is not in the cards at this time. I still lean towards a physician for physicals because I don't know what he might see that would concern him. It was a primary care physician doing a routine physical who discovered what turned out to be a rare high grade and aggressive bladder cancer before it got too far. I did not have any of the risk factors, and was well younger than most patients. In a family where many have died of cancer I am literally the only cancer survivor. Maybe a PA or NP would have discovered it too. That's not anything I can know but the experience made me somewhat conservative in my approach.

    I apply this same approach to whether I seek care at the small regional hospital (I live in a rural area) that is only 10 miles from here vs driving two hours to a large teaching hospital. They each serve a purpose and those purposes are different.
     
    GrignardsReagent likes this.
  27. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    For patient one, what the heck is that Mad Jack??? lol I'm going to be totally honest, I've tried looking this one up, and I even asked a few of the physicians I work with and none of us can say for sure what that is...Is it a contact lense, Pterygium? I already said aniridia but you said that's not what it is.
     
  28. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    [​IMG]
    It's a normal eye.
     
    Staphylococcus Aureus likes this.
  29. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    lol okay! We're talking about this image right?
    [​IMG]
     
  30. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

    30,147
    50,528
    Jul 27, 2013
    4th Dimension
    Yep, totally normal eye. Number two is Wilson's disease.
     
  31. FNP_Blix

    FNP_Blix

    173
    8
    Jul 21, 2017
    Darn, I missed the kayser ring. Showed that to one of my docs here too just a couple of minutes ago and we both thought melanosis cause of the brown discoloration on the sclera.
     

Share This Page