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Why Nurse Practitioners Should Not Do Primary Care Without Physician Oversight
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Former pediatrician and infectious disease epidemiologist. Just thinking about a NP diagnosing me, without sufficient training, or medical school, just makes my blood boil. My question is, why is there a shortage of Doctors, and how can we resolve this issue without degenerating the entire health system?
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Perhaps if med school was more affordable, that would help some. Even efficient computers should help , by getting more done in less time. Who cares about the middle class and poor shit? They are sending a message that their health is not as important as those who can afford a qualified doctor.
We have to stop this from happening. Demand to be treated by a doctor. You are not even an American! Foreign people come over here to make money and then have the nerve to criticize out health care. I am a PhD chemist. All have been highly trained, skilled and have longevity of practice. You are arrogant and wrong! I have been a NP for 12 years in primary care. I am in a state which allows independent practice. I ran a satellite office for four years by myself. I had a pediatrician who would come in for newborn checks two afternoons per week only and we alternated well checks until the child was two years of age at my insistence.
This is an advantage. I know when to ask for oversight. In my previous practice, we hired H-1 physicians as we were listed as a non-profit. Many unfortunately could barely even speak English and had difficulty obtaining an accurate history, so your article is crap. You should be ashamed of yourself. We are intensely focused on make care super convenient, quick and easy, and inexpensive by providing care via app or website. We currently provide treatment for simple uncomplicated primary care issues like acne, bladder infection, birth control medicine, heartburn, hair loss, and sinusitis among others.
We look forward to making more services available as we expand to more states. Sorry if this upsets anyone, but I am very scared having these people unattended. I have no medical degree, yet I have been much more knowledgeable then any nurse or PA I have ever encountered. Well, I guess it would be if I wanted tendinitis or other antibiotics have previously failed.
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Needless to say, I finally made it back to my doctor in the same practice and he was shocked that she would only prescribe for an issue like that for 7 days and of course wrote me a second prescription for the rest of them which I had to pay for twice. He then said he would speak to her and explain to her how to prescribe antibiotics for a sinus infection.
If you have no clue how they even work and what the severe side effects could be then you have no business writing prescriptions. At this rate, anyone could just go off the street and become a midlevel provider. What was even more appalling was during the same visit, a lady was sitting there doing nursing duties checking bp and blood sugar ect who turned out to be an X-ray tech!
I was horrified when I figured it out and there was no doctor present at all at the clinic. It was shocking and completely out of control. As a patient, I have lost complete respect for nurses over the years. They want to play doctor yet every single one I have ever seen has given me false information or have not had the first clue on what they were talking about. Then I magically see a doctor and he understands exactly what I am talking about and the issue so I can get the correct treatment. And the way I see it as a health care customer, aka patient, is that NP or PA visits should only be half the price because you are only receiving half the care.
I hate to sound rude or disrespectful in any way. I know they try, but after repeatedly being misdiagnosed and mislead by non-doctors, causing a delay of real care, it has really shown me that are not qualified to play doctor. Blood pressures and venipuncures are some of the first things we were taught in my program. But I agree with you about nurse practitioners. On average I would much rather be cared for by an M. The way I look at it, if you do the schooling and receive your doctorate in any form of education, you are entitled to be called a doctor, period! After reading over all of the comments I felt compelled to comment myself as this single post has generated a two year debate.
The ongoing struggles between mid level providers and physicians grows stronger as payer systems shrink and the cost of education rises. At its core, the art of medicine is now an evidenced based conglomerate which has been marginalized by a database that can be accessed by anyone including physicians, midlevel providers, and even the layman.
I feel like it has convoluted and blurred the lines to a point where a new struggle has emerged trying to figure out who runs the show, who should be paid the most, and who should call the shots. I, like many here have seen both sides of the spectrum in regards to quality of care which is affected by many aspects including demands of institutions, apathy towards ones profession, and lack of knowledge. One thing that has stuck with me over the years is something a seasoned colleague once told me and is echoed by the NYT article: We can all benefit from that fact.
My training was at a university level and mutual respect was common practice but there is always an unspoken undertone that I think you can feel. We all want to be the best and while doing work that oftentimes requires a level of confidence, I believe it is unavoidable not to have confrontation of ego and an ability to believe that your plan is the only plan. Nonetheless I routinely perform many of the skills that have been outlined above not limited to emergent resuscitation, intubation, etc. I do agree that a strong base in physiology and more importantly pathophysiology and an avoidance on the reliance of diagnostic tests does allow us all in the profession of providing quality of care clears way for the construct of medical care.
I do believe too however that experience and exposure to multiple versions of the same thing and atypical presentations are very valuable in being a well rounded provider. I am hesitant to say which side of our debate that I am part of so I want to leave that part anonymous. I will say that at the end of the day, no matter what profession you have decided to undertake physician vs nurse practitioner vs physician assistant , make sure that you understand that your limits are defined by your understanding of basic knowledge of biological science coupled with the experience you have gained based on the environmental diversity that atmosphere can provide.
I hope this conversation will continue with a less callous approach on both sides of the spectrum. As a nurse practitioner I agree that doctors are the people with a medical degree and that their training leaves them better prepared Of course training and preparation costs and is becoming increasingly expensive. I would argue that training needs to change to address the accessibility of appropriately trained competent individuals who can treat patients be these doctors, nurses etc At present the elitism in access to medical school has excluded many able intelligent people from reaching their potential and we have a shortage of both nurses and doctors.
You neglect to account for the clinical hours as a registered nurse. I have 10 years as an ICU nurse before I applied to my primary care program. I have met far more idiotic MDs who entered the profession solely for the prestige and could care less about the patient. There are exceptional practitioners and lackluster ones in ever field.
Not to mention NPs must be rectified far more frequent than MDs, and for some specialties recertification is only recommended not mandatory. The decision to become an NP is not one entered into lightly and we ate fully aware of the differences. Hence we study day and night, join associations, subscribe to every EBR journal, and do everything to be as informed as possible.
Not to mention consult with physicians. If only they spent that time working with patients instead of pushing the propaganda and making these huge claims that doctors only care about the disease and not the patient. Every medical school teaches about treating the patient as a person. Their entire motto is treating the patient holistically. The kids from my college and high school who went onto become nurses and nurse practitioners were C students and many of them were dumb as a rock.
But now they flaunt their DNP degrees they got from Online Nurse Practitioner school where you can make up your own clinical hours and have them signed off. Yeah good work controlling glucose and blood pressure. Oh great nice to meet you Dr. Gold, Is there anything I can get you? Who the hell is my real doctor!!! I love the nurses coming on here and bashing physicians. Why not be truthful as to how one obtains a doctorate in nursing. Several advertise little to no time on campus. Tests are honor systems. No classes really on medicine. Most classes on administration and other.
Or when a simple diagnosis is missed because of the lack of training. It is the patients responsibility to do their homework on who is treating them. ANYONE who makes wide over reaching claims that encompasses entire groups of people is probably unaware of how the system actually works, or works in the field and is insecure about their own quality of practice.
A Full time Nurse will work 1, hours a year in medicine and most reputable schools require 2 years of nursing experience prior to applying to the program in addition to the clinical rotation hours mentioned above. Good Vanity Fair article piece regarding the Air France crash and the differences in quality of experience between the two pilots. The crew arrived in Rio three days before the accident and stayed at the Sofitel hotel on Copacabana Beach. At Air France, the layover there was considered to be especially desirable.
Dubois had come up the hard way, flying many kinds of airplanes before hiring on with Air Inter, a domestic airline subsequently absorbed by Air France; he was a veteran pilot, with nearly 11, flight hours, more than half of them as captain. But, it became known, he had gotten only one hour of sleep the previous night. Rather than resting, he had spent the day touring Rio with his companion. Flight took off on schedule at 7: The Airbus A is a docile twinjet airplane with an automated cockpit and a computer-based fly-by-wire control system that serves up an extraordinarily stable ride and, at the extremes, will intervene to keep pilots from exceeding aerodynamic and structural limits.
Though he was the Pilot in Command, and ultimately responsible for the flight, he was serving on this run as the Pilot Not Flying, handling communications, checklists, and backup duties. Occupying the right seat was the junior co-pilot, Bonin, whose turn it was to be the Pilot Flying—making the takeoff and landing, and managing the automation in cruising flight.
Bonin was a type known as a Company Baby: By now he had accumulated 2, hours, but they were of low quality, and his experience was minimal, because almost all of his flight time was in fly-by-wire Airbuses running on autopilot. Your article is simply regarded as personal opinion without such. As for my opinion about you, again just as validated as your assumptions, you see patients over an app.
Wow, this seems very safe alot safer than an NP seeing a patient in person. No wonder you are blogging. I guess you have to make your money somewhere. I would like to make an observation in regards to the assertion and argument of interchangeability. NPs can and do provide many of the primary care and acute care services that Physicians do in the same setting. Just as a PCP may provide much of the same care to patients with heart disease , yet it does not make them a cardiologist.
The question arises, does that mean they are inferior in managing hypertension? I would never equate the care I provide to my patients as being the same as a Physician, nor would I want it to be. I relish my training in relationship based care and focus on evidence based practice. But I will assert the quality of care provided within my scope has been proven repeatedly.
Personally I find the ongoing attempts to compare and place NPs and MDs in some hierarchal war tiresome. I would encourage those who dismiss the role NPs play in the growing healthcare environment take a moment to examine the numerous RCTs on outcomes, and patient satisfaction. This entire discussion has further secured my decision to go into speciality care. My team members and colleagues have embraced my position and approach. Just as I consult and refer to them for a positive stress test or for worsening valvular disease they in return consult and refer to me for the ongoing management needs of their chronic cardiac disease patients.
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Team based disease management and care is the future of healthcare and those who refuse to be a team player will find it difficult. No longer do the initials behind ones name mean they are at the helm. And one last observation, NPs are not Physicians but they most certainly can be Doctors, as are most professors in Academia, as are some Pharmacists, as are Attorneys.
Good luck and thanks for your insights. I function as in independent provider in a hospital clinic. I also interpret those results and treat accordingly. This being said, I have numerous cardiologists available by phone if I have a question I consult with them. The same as any provider would; the same as you do I am sure for tricky dermatology issues, renal failure or cardiac sarcoidosis. On numerous occasions our Cardiologists have said something to the following.. Our NPs know what they are doing and they do it well.
Otherwise we just get in the way. Ultimately it is about trust… I certainly hope one day you will have the opportunity to work with more NPs and you will be open to giving them an honest assessment based not on assumptions but on their outcomes, knowledge and abilities. As a MD, details matter! Congratulations on knowing how to spell, and count! I would still argue that being able to take and pass four tests does not prove anything. I work with residents in family medicine, as well as work in the training of student nurse practitioners. Experience is key, the difference I see is attitude.
A lack of humility, and a sense that they think they know it all from medical residents is continuous as it is obnoxious. Your post only shows that you are bigoted against mid level providers. I would suggest that you retract this article and spend some time getting to know your NP and PA colleagues, and try a little humility. Any idiot can use spell check. I have all respect for MDS.
I also respect nutritionists, LCSWs, etc. The God complex of doctors needs to go because it is a team effort to get the patient the healthiest possible which is still the goal right? What they need to do is focus on PAs. Heck PAs can have a bachelor in business and only 2 years in medical field prep. I agree that Nurse Practitioners need more clinical hours. I feel like the first year of FNP school was still talking about stupid nursing theory.
I would rather start into shadowing and clinical experience for an entire extra year. I think the schools are doing Nurse Practitioners no favors. I have had many physicians miss a diagnosis I have caught. I knew the answer from being a RN and not from school. Also, I have had many physicians diagnose me incorrectly and not listen to me. Let the statistics and patients tell you the truth. It seems sad to me that physicians often feel threatened by NPs.
I should clarify what physicians missed. They were wrong and in very serious cases with potentially scary outcomes. So while I respect the thought that you are concerned for the patients, I am hoping that is the essence of the article, I would heartily disagree with your assessment of ALL independent NPs. This is an interesting thread, and I see some very passionate responses. I think there is a traditional patriarchal understanding of what a nurse does and how much they know.
Education in nursing is always evolving as is medical science. I have been a nurse for a long time, and also have seen awful conduct by physicians; however, that being said, I do think that they are essential to a multidisciplinary team. All our specialties are made to provide the best care in a team approach. One of the issues is that nurses are allowed to enter practice at various levels of education. This may be the crux of the problem that physicians have with us practicing primary care.
As much as all of us would like all nurses to have a doctorate degree, its just not likely to happen while there is such a severe shortage of healthcare providers. That being said, a doctoral prepared nurse has had years of experience, and has likely had more time with patients than a physician coming off of residency. Do new physicians need oversight if they were to open their own practices? We should embrace each others capabilities, and not say that one is better at providing care than the other, because its not the truth.
The Institute of Medicine and the Robert Wood Johnson Foundation advocate for nurse practitioners, and its too bad that there are some standing in the way in improving access and health outcomes by impeding NP progress. That is a protected title for them!!! Doctor is not,many other professions have doctorate degrees,which entitles them to be called DR. This can include nurse practitioners. Physicians have more training and they are a precious commodity,however nurse practitioners are severely needed in medicine also and can handle the challenge. Physicians will always be needed ,especially in specialties,so I do not understand what they fear.
First, I note the wide variation in egocentricity among the NPs commenting. This appears in two areas in the comments: Big egos are dangerous. The second area I note relates to claims of equivalency in training. Yes, I know that a lot of NPs are plenty smart, but getting into a nursing program is not even close in competitiveness, and much of the coursework is far less rigorous compare typical requirements for organic chem and biochem, for example.
They are absolutely necessary, and in very small communities independent practice may be the only option to provide any health care at all. Also, I note that after the first confusion and presentation of evidence, she admitted her error and apologized—a big ego sort might well have argued right to the wall, and that is not acceptable.
Would be interesting to compare this statement with the ED. I have always suspected the ED to be the front line introduction. My observation has been most new patient referrals to primary care come at discharge from a hospital say. The first of the 3 screw ups was the only one to properly identify themselves as not a doctor. I tried to book an appointment with my primary care today and I was asked if I would see another doctor in the practice. I was lied to! It is absolutely an ethical issue!
Not only is this person not gone through same training as a doctor but they are going to charge me as if they were a doctor! If you want to be a doctor MD or DO go to school, that is all it takes. Save the time and go to school. I cancelled the appointment today right after I found out I was lied to.
So thank you for educating me on that. Maybe that will help with improving quality healthcare future patient gets. Firstly; need to think of the patients. There is a shortage of primary care doctors and the number of residency spots has never increased and no plans to increase. So how do they fix this? I think there is a huge need for NPs in the right setting.
If I was an np I would not want to practice independently. Some of my good dear friends have transitioned to np and I am always a text away to help answer questions. I have worked with nicu NPs and they were amazing! They so sweet and cared and read up on stuff and were so enthusiastic to learn more and get better skills. I other areas I have not seen the same. I had np in the nursery make a massive error with my own baby. I have seen massive errors and oversights by NPs in general practice and ed mostly and if I made same I would be in trouble. Unfortunately my np counterparts want to get the job done and move on.
My other friend is a nurse and I am encouraging her to become an np so she can work with me and I will teach her gladly. I discuss patients all the time with colleagues and discuss management as I always want to keep on learning. I also worked down in radiology, NPs and pa were frequently bought up and not in a positive light reason: Massive amount of mris ordered for headache and back pain.
Maybe if in primary care NP could have a list of specific diseases that they receive medical boards level training so that they are solid at and have them mange those issues. NP are amazing for diabetic patients and managing their diabetes. I looked at the first image: That kid was full of stool. Constipation is first on differential for abdo pain in a kid. When I asked her about the stools, she had never asked the patient, asked me to hang on while she asked when we were on the phone.
That kid ended up getting transferred to surgery, had an ostomy placed. Np missed an medical emergency diagnosis of HUS, sent the kid to the pediatric medical floor, I immediately had to transfer to picu. Np missed diagnosis of new onset diabetes. All of the residents were laughing at the note it was so bad.
Listed assessment as symptoms: Then the labs showed a glucose through the roof but she had no clue what she was doing.
Np without attendings consent did a large volume LP on a patient who had a previous Ct head showing Chiari 3 malformation, well your not supposed to do that. Patient herniated and died. This is where np and pa lack training. How can it be fixed so patients health is protected? And how can it be fixed so np and pa can practice within their scope? The people stating they will never see a PA or NP are idiots. Blanket statements are really ignorant. I find older adults 65 and older have a real problem with non physicians providers. Then go see a physician,stop crying about it.
I guarantee as soon as something happens they will be crying about their physician next!! Most people already think they know more than all these physicians and providers anyways! Its about the attitude and the personality of the provider treating you,not the number of school years they have! You want to know where the most terrible Physicians are? The idea that people are contending that they oppose primary care being performed by midlevels because they care sooooo much about patients is even more ridiculous.
Well, that Caribbean med school she went to sounded pretty intense…. Ultimately I find the whole argument to be disturbing. What is most concerning about NPs is their limited training. As an attending in a large teaching hospital I have the privilege of precepting many Physician Assistants and Nurse Practitioners. The training and learning for Physician Assistants continues throughout the career as well with CME and recertifying to prove competency. NPs are given the benefit of the doubt through the vast nursing fraternity that exists.
Some dangerously completing programs solely online, not so much as seeing a cadaver let alone a gross anatomy course. There is no consistency in education, schools even allow NPs who just completes a bachelors without a day of bedside. In my honest opinion NPs are a danger to medicine. There practice model needs serious review for the safety of patients and society as a whole. I have many colleagues who refuse to hire NPs in their practice for this very reason.
While there are some interesting things discussed here the general feeling from this article is that all NPs are the same and that they are inadequate providers compared to MDs. In fact there are good and bad providers in both professions and it all depends on each provider. To say that more training is better for MDs is misleading since a lot of their residencies are spent sleeping in hospitals until some emergency calls them in the middle of the night. To add those hours to accomplished training with their normal rotations is inappropriate.
NPs on the other hand may not have as much residency and total hours of clinical training in schools but most have worked in hospitals or clinics for years and have learned enough about the system to do excellent work in primary care. I take this article with a grain of salt when it comes to primary care provision. Its not rocket science and there are many guides to help when the unusual situation presents and there is referral for such cases or if a provider feels out of their role.
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Time for the bashers to realize the need with override their hindrances and bias. I go into the emergency room, biggest offender. They even use as a study for their PAS. I asked what doctor is on and they tell me. How dare they put me with somebody other than a doctor. Make the others go to school and quit screwing my medicare and my Tricare for life insurance. That is all I have to say and I wish somebody out in the world had the lugnuts to call out all the hospitals in this great country of ours. While I am at it. The Veterans Affairs does a great job to a point. ALL the veterans teeth.
Why are they not doing it its beyond me when it caused infections, heart disease and sever pain and suffering. I know I took care of a platonic friend for 10 years and 7 months and he passed this past May. I know what it does. Then they get depressed and they stop talking or wanting to do anything.
ALL of which my friend had. Thank you for the opportunity to for me to let somebody know. Plus these studies are all over 6 months…. That is not long term outcome!!!! I agree and disagree with both sides. There are multiple variables to consider when it comes to practice authority based on license and practice requirements. Nurses are not doctors, and doctors are not nurses. Their practices are independent and not dependent.
At the same time, there is a growing problem that will have a direct impact on the care of patients over the next years and that is the current practice of nursing colleges allowing nurses with little to no practice experience enter and graduate as nurse practitioners. I am sorry but nurses should not be allowed to become nurse practitioners until they have worked as a nurse full time to gain the education and experience needed to develop strong critical thinking skills.
This can not be taught in nursing programs. A nurse practitioner without experience is a death sentence to the profession and patients. It used to be that nurses did not qualify for nurse practitioner school admission without a minimum of 10 years of clinical experience. Now nursing programs are admitting any registered nurse regardless of the lack of experience. The handwriting is on the wall, mistakes will be made and malpractice incidences will escalate. We are forcing med school students to spend waaay too much on a medical degree to deliver primary care, and its a shame.
We do a great job… stop the turf war garbage. Anecdotal stories make people sound ignorant… evaluate the research, and the answer to our primary care shortage is obvious…. I have worked in large inner cities and small cities. By no means do I want to be a psychiatrist- but I do plan on delivering mental health services in rural areas.
Most rural areas dont have access to mental health services, let alone primary care physicins. I have worked and collaborated with several psychiatrist over the past 15 years. I will continue to collaborate once I graduate. In addtion I will use my past experience coupled with evidenced base practice to deliver safe and competent care. I will provide psychotherapy and medication management. I will not let a physician dumb my abilities and education down. Med management with psychotropics takes art and skills.
Let the client sit on a 3 month waiting list to see a psychiatrist. We will hope and pray the client doe not self harm or harm anyone else….. You are basically just a horrible person and a bad clinician if you think that MDs are the only providers capable of quality patient care. In , researchers looked back at data from to examining the number of medical malpractice claims among various types of medical providers.
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Just because you are an MD does not make you better than an NP. I have met many MDs with God complexes and think they walk on water and have the bedside manner of a rattlesnake. I have had NPs that have given me the best care I could ever imagine. I feel a lot of it has to do with the money MDs will lose if NPs become autonomous and start taking patients away from MD practices. I for one wish to collaborate with practitioners that have been in the field longer than I have. To have an attitude of cockiness straight out of school is a dangerous game and we should all work to build one another as colleagues rather than acting the way we are now.
I have been prescribing as a PA for over thirty-six years. I say that to give you perspective. Like much of what we do, we have proven ourselves. This innovation of a non-physician clinician has been successful. The jury is no longer out. While PAs and NPs may somewhat differ on philosophy, in my humble opinion we all practice medicine. All three professions need to know that one way. We use the same textbooks as physicians do to learn.
We use the same language, write the same prescriptions, use the same instruments. I feel you have never really realized or recognized that. You certainly have not embraced that. While many individual physicians have been wonderful in their support, organized medicine has a long record of opposition to both professions.
That hurts the people who are closest to you in the medical world. Many physicians love the PAs and NPs they work with. When it is legal, many have made us partners in their practices. Others only like us, and some barely put up with us. We practice in almost every medical specialty. Having been a national organizational board member and president of the PA society in the state with the largest PA population, I have generally seen the medical society of my state and other states committed to time and time again putting out a negative spin about us.
That, my colleagues, is a crucial mistake. It shows you are not captain of the team but instead are committed to not even being part of it; or at best, not having the team be all that it can be. Team members should there for each other. Negative rhetoric does not help anyone. What would help is each of us recognizing and embracing what all professions bring to the table. You cannot keep any profession from evolving. Even today, any move for PAs to evolve and grow as a profession is met with a negative knee-jerk reaction from the state medical society or national organized medicine.
Even to say we provide medical care is met with physician sneers. I say this not because I want people to think I am a physician please realize that is not the goal but simply because it is the school I went to. I studied medicine there. It may be just my personal feelings, but I feel the physicians of America have never realized this.
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