A nurse may soon be your doctor. With a looming shortage of primary care doctors, 28 states are considering expanding the authority of nurse practitioners. These nurses with advanced degrees want the right to practice without a doctor’s watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called “Doctor.”
For years, nurse practitioners have been playing a bigger role in the nation’s health care, especially in regions with few doctors. With 32 million more Americans gaining health insurance within a few years, the health care overhaul is putting more money into nurse-managed clinics.
Those newly insured patients will be looking for doctors and may find nurses instead.
The medical establishment is fighting to protect turf.
It’s about time. NP’s are great!
Well, they are but they are not doctors. In this state, they have an ever increasing role and for some it is good and for others it isn’t.
They need supervision and that demands more of the Doctor’s time then most realize and as the pressure is increased mistakes will be made and people hurt.
This is really an expansion of military medicine verses civilian medicine.
Which model is best when you do not have enough doctors to meet with everyone. That is what this new health care model is about….coming down to the lowest common denominator rather than keeping standards high.
Even doctors standards will be lower so that more can graduate…and yet, if they cannot pay their loans and school debts because of lower income, then fewer will be likely to go this route.
The ramification of this new legislation is far reaching and hard to see but in the end it looks like more people may be covered but at what a cost to people, care, and practice?
Rev. Patti Hale response is shallow and problematic on lots of counts.
There are obviously some great nurse practitioners and I work with many but the reality is that it is easier to get into nurse practitioner school than medical school.
We are facing a huge shortage of primary care physicians (and to a lesser degree specialists in most fields as well). What will be the effect on primary care physicians with a large influx of lower paid professionals? And I am not being sexist, but NP’s are overwhelmingly female. As the field goes from primary care physicians to primary care practitioners with a larger and larger share female, the outcome is obvious. Less and less medical students will go into primary care specialties instead of more. In fact, I would most definitely discourage any medical student to go into a primary care specialty at this point.
So hooray, Rev. Patti Hale.
Robroy- Here is my shallow and problematic reasoning…. based on my own experience, of course. NP’s give excellent care, especially if you are like me- generally healthy and have no major complicating conditions. NP’s also, in my experience take time with their patients. As far as decent medical care- I want someone who knows what they are doing whether male or female. Do medical students really decide which discipline they will practice based on the prevalence of male or female colleagues? Talk about shallow and problematic! One would hope people become medical professionals because they are dedicated to health and love people.
While the family practice my family goes to has a nurse practitioner on staff who is great for giving my daughter her sports physical, my experience with nurse practitioners in the VA and PAs in the army has left me unimpressed. They hve their place, but no replacement for MDs in primary care.
It is an unfortunate but unquestionable reality that professions that are perceived as “female professions” have lower salaries and have less qualified applicants. Look at the teaching profession, which I see as one that should be one of the most valued by our society but is ruled by the “those who can’t, teach” dictum.
Medical students are graduating with ever increasing debt loads. They are not stupid. Why go into primary care when you will be competing with nurse practitioners calling themselves doctor and are pushing salaries lower and lower? They won’t. That is bad. When you are older, perhaps have had an MI and develop rheumatoid arthritis, you will want a PCP that can handle the complexities. Absolutely there are some NPs that can and some physicians that can’t, but if primary care becomes a triage specialty, it is the complicated patients that will suffer.
“We’re constantly having to prove ourselves,” said Chicago nurse practitioner Amanda Cockrell, 32, who tells patients she’s just like a doctor “except for the pay.”
I am a NP, and this statement is completely untrue. And if they’re aiming for 100% of physician reimbursement, then they’re seeking status and power without training, which is a fool’s game.
(Usually) “We are women; hear us roar, we are or can be the same”…sure you can, just go to medical school. If you can’t or can’t get in, then I guess you have to accept your limitations, instead of practicing beyond your scope. Because sooner or later, that WILL come back to bite you, just like it would bite a doctor…you don’t see an ENT doing heart surgery. And ultimately it’s the patients who will suffer from your egos, misdirection, mischaracterization, and “validate me”.
I’m female, too, and in full agreement with robroy. NP’s were originally conceptualized, like PA’s, as “physician extenders” where they handled patient teaching, the care of minor illnesses and problems, and health promotion/preventive medicine. Tacking on to that without the proper training is wrong. Teaching or learning from the medical vis a vis the nursing model is DIFFERENT. Nursing PhD programs are largely geared towards teaching nurses to teach OTHER nurses, not become MD’s. The curriculum, time spent in clinics, training and focus are NOT THE SAME.
Were I able to do it over again, I would become a PA, taught by a medical model. Doctors and PA’s are clear about each other’s roles and what each can and cannot do. PA’s go into the job knowing that supervision is obligatory, and thus have no need or avenue to get too big for their britches.
It may be “easier” to get into medical school, but that’s because medical schools are monopolies. They have an economic interest in ensuring that some talented students don’t get in. I’ve known several dull doctors and smart medical school rejects. And in the rest of the world, medicine is more like a craft than say… an entitlement into the upper middle class.
I’d also say that Robroy’s comments reveal more about the pervasiveness of sexism than about the dearth of good teachers. After all, I do trust there are good female doctors; and male nurses, and I’m unsure how Robroy would quantify excellence.
I’ve had great experiences with NPs and PAs. I don’t expect they knew any less than doctors. They just didn’t have the degrees.
I would add to Bottom Feeder’s note that just at the time that when nurse practioners could expand their role, they are cutting off the future supply by requiring new NP’s to have a “doctorate”. Of course, the ones already working will be grandfathered in. (Should I say grandmothered? No, I won’t go there!) I think that PA’s will step into the gap.
I absolutely do agree that NP’s and PA’s have an critical and vital role to play if we are to fix this mess. Undercutting physicians, however, will have bad unintended consequences.
I’m in great health — and I’ll be seeing a physician not an NP, thanks.
Of course, all of this is about the State desperately needing to cut costs, while pretending to offer the same level of care. And what happens — an inferior product — the NP’s training — is pawned off on the unsuspecting.
I sure hope everybody has their own primary care physician lined up and locked in — the next five years until this thing gets repealed are going to be rough.
Let’s be really clear: a Nurse Practitioner is NOT a Physician’s Assistant but also not a Medical OR Osteopathic Doctor. They are three different disciplines, each with its own professional and educational requirements, and each with its own scope of practice. A Nurse Practitioner is equipped to diagnose, treat, and manage a variety of conditions with minimal or no “medical” supervision (depending on the state.) A Physician’s Assistant MUST be under the direct supervision of a Medical doctor (I think in some states the PA may also be supervised by an osteopatic doctor but I’m not certain of this.) An MD or OD is also equipped to diagnose, treat, and manage a variety of conditions. The difference between the NP and the MD is in the scope of practice and the areas of practice. A NP is NOT prepared to perform brain surgery. A MD is not always willing to practice in the family practice arena.
You know, in Corinthians it says there are varieties of gifts; this is true in health care, too. If we had been smart (like the states of Washington and Oregon) we would have been encouraging NPs into independent family practice much sooner than we did. They can provide for MUCH–MOST!– of the normal health care for a family including childbirth, child care, geriatric care and chronic medical conditions. Doctors DO have their places in a health care system but health care COULD be expanded with thoughtful and considered use of ALL the providers.
One is NOT better than the other; to use a MD when a NP is available and qualified is mindless and expensive.
“What’s the evidence on the quality of care given by nurse practitioners?
The best U.S. study comparing nurse practitioners and doctors randomly assigned more than 1,300 patients to either a nurse practitioner or a doctor. After six months, overall health, diabetes tests, asthma tests and use of medical services like specialists were essentially the same in the two groups.
“The argument that patients’ health is put in jeopardy by nurse practitioners? There’s no evidence to support that,” said Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health”.
Drawing such a conclusion based on one study of 1300 people, without a discussion of the limits of the study design, variables that could not be controlled, etc., denotes a pretty poor grasp of research techniques and scientific method. The bare-minimum competent thing to say is that more studies are needed. There may not be evidence to “support that”, but there is also not evidence to refute it, either. The “unsupported” statement is misleading to the general public.
Frankly I’m tired of people equating quality health care with the amount of time a provider spends with them. One truly has nothing to do with the other…I’ve had my OB’s spend 15 quality minutes with me sometimes, and once I spent about an hour with another NP, who proved herself an utter flake. Needless to say, in that case I “doctored” my own problem until I could get in with my PCP.
Dr. Joan, I’m glad physicians have a place in health care.
My own personal preference is that I want my internist to know me and my conditions. He has terrific PAs and NPs in his practice, but my principal relationship is with the physician, and I am offered the opportunity to see them instead of him. However, I chose the medical practice based on the MD, and not the others, and would choose to leave it if I became dissatisfied with the doc or if he left. The NPs and PAs come and go. When I go to get my physical or get sick, I want to see my MD, and not to be relegated to his NP. I am perfectly willing to have the others do follow on care or monitoring, or to provide the usual care that nurses provide, but I want the quarterback for my health care to be my doctor.
By the way, I am NOT a physician but a nurse. And I am NOT a nurse practitioner.
But I do choose to go to a Nurse Practitioner!
Would NP’s cost less to see than MD’s? Does it matter? The goal has been to get more MDs to be General Practitioners. If the field is opened up to NPs I would expect fewer MDs to choose this rather than more. Why spend the years to go to Medical school? Seems to me we need to decide what the real goal is.
I’m sorry for my convoluted posts; I keep getting interrupted.
Rob, thank you for saying the thing about the doctorates; that was the next thing I was going to say. And I agree that PA’s will fill the vacuum. Cutting the population by requiring that nursing position to be PhD-prepared is asinine and also will not add to the quality of care delivered by NP’s.
When it comes to a nursing education, bachelor’s degrees are basically taught to be “practitioners”(excuse the use of the word for a minute), master’s degrees are taught extended clinical practice and research techniques, and PhD’s are taught theory-building and stuff like curriculum development. It’s not a program like the clinics of the last two years of medical school, or the intensive hands-on, mentored, supervised phenomenon of 3-7 years internship/residency/fellowship.
At this point, if I reenter the workforce it would probably do me good to do an intense 2-year program on top of my other schooling to simply get a PA certificate. Were I a PA now, I’d be happy about my increased job opportunities and security while, as usual, the nurses eat their young.
I could attempt explaining that to the FemiNazis at ANA, but I’d have better luck with open minds if I was talking to my basset hounds.
RE: “One is NOT better than the other . . . ”
Well no person is intrinsically “better” than another. But I differ on whether a physician or NP is suited to oversee my health, and in that context, when I want a person gifted in medicine, a physician’s gifts and training are vastly superior — in my view of course — certainly others may decide for themselves.
I don’t know that I’d say “superior”, but I’d certainly say “different” and it has to do with what makes people “qualified” to do what they do. You don’t visit your electrician for a haircut, unless you want a REALLY bad one.
Thank you #11… You said it much better than I did.
[blockquote] It may be “easier†to get into medical school, but that’s because medical schools are monopolies. They have an economic interest in ensuring that some talented students don’t get in. [/blockquote]
I have no idea what John (#8) is talking about here. What is the economic interest?
[blockquote] I’ve known several dull doctors and smart medical school rejects. And in the rest of the world, medicine is more like a craft than say… an entitlement into the upper middle class.[/blockquote]
This is true. One aspect of medical school admissions is that they don’t weight undergraduate GPA’s enough. A C- grad from Harvard beats out a A+ average from Southern North Dakota Teacher’s College, but the way many med schools filter through the applicants, the C- Harvard grad won’t even make the first cut.
[blockquote] I’d also say that Robroy’s comments reveal more about the pervasiveness of sexism than about the dearth of good teachers. After all, I do trust there are good female doctors; and male nurses, and I’m unsure how Robroy would quantify excellence. [/blockquote]
Right and wrong. I am saying the obvious – that professions that have the perception of being a “female” profession have lower prestige, lower salaries and less qualified candidates. It would be a bad thing for primary care to have this perception – it already does unfortunately to some extent. I am saying NOTHING “quantifying excellence” and about male versus female physicians or male versus female NPs.
The only thing I could say is that female physicians tend to worker hours (49 versus 57 hours) and have shorter career lifespans. This is one of the reasons why they blew it on predicting physician supplies because they didn’t take into account that medical schools are now ~50% females. In the 90’s, they were talking about an oversupply of physicians! For very interesting details, see [url=http://bhpr.hrsa.gov/healthworkforce/reports/physicianworkforce/female.htm]here[/url].
Sorry:
…female physicians tend to work fewer hours (49 versus 57 hours)…
drjoan and Rev. Patti Hale:
Nurse practioners and PA’s, from the get go, were physician extenders. What we see here is that nurse practitioners are making the move to get out from underneath physician oversight. What I am saying is that this could be VERY bad for primary care with physicians abandoning it completely.
Primary care is hard. You see relatively normal patient after relatively normal patient. The good PCP is the one that sees a patient with cough and realizes that this one isn’t just another viral URTI but a lung cancer. This intuition is developed and honed in training. And big outcome studies, like the one that Bottom Feeder cites, don’t see this because the patients are outliers.
From the article:
[blockquote] An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60.
The health care overhaul law gave nurse midwives, a type of advanced practice nurse, a Medicare raise to 100% of what obstetrician-gynecologists make — and that may be just the beginning.[/blockquote]
This is outrageous. If a Ob-Gyn is delivering a baby, he or she should most definitely get paid more. Why? Because if something goes wrong and the baby is crumping, the Ob-Gyn can do a crash c-section a mid-wife can’t.
“What we see here is that nurse practitioners are making the move to get out from underneath physician oversight”.
Rob, I don’t know how long you’ve practiced, but they were trying to do this even in ’94 when I graduated NP school(masters level). I’ve never agreed with it, because it wrongfully overhauls the original “physician extender” philosophy/role definition.
Unfortunately they’ll do it until one of them has a high-profile misdiagnosis and loses a patient or patients, but that won’t bring the losses back. Then they’ll try to blame the supervisory physicians for not being “available enough” or “collaborative”.
And I also don’t agree with full reimbursement for any physician extender when they are not 100% responsible for the care…and states that allow them to be are foolhardy when the training is not geared towards independence as medical(MD) training is. Extender care out in the backwoods of Montana may be better than no care, but it is not the same as physician care.
And I fully agree with the OB reference–when my OB/GYN friend had 26 week-twins crash on him in a tiny, rural hospital, it was damn lucky for the mother and babies that HE was in charge, not a midwife…and he and the neonatology team he had flown in from the Metro area two hours away earned every nickel of their 100% reimbursement.
I loved the military medicine system and the medics. Doctors were in charge and medics did all the routine stuff. I have worked with NP for many years and really appreciate it all. We don’t have PA’s in our area, but one of our colleges is starting a program. My doctor friends say they are wonderful. That being said, most office visit problems are very routine and most would do just as well if they didn’t come. But in the crunch you need a fully trained doctor, either MD or DO. A pilot with about 100 hours total time can fly a 737 quite well. Our B17 and B24 pilots in WWII had about 200 hours and were about 21 years old when they went to England to bomb the Nazi’s. About 25% died there. An airline captain has at least 1500 hours at the least. They may start at 700 hours in right seat position. Now most flights are very dull and routine, but how many of you would like to be piloted by a 200 hour pilot during the Hudson River crash? Capt. Sollengburger had lots of military experience and thousands of hours. His first officer I believe had over 7000 hours. He addressed Congress and warned that we were running out of high time pilots or those with military backgrounds. But usually that isn’t necessary. If something happens the lawyers will always try to show that the doctor just didn’t know what he was doing. but usually it doesn’t matter.
As for PCP, I don’t see a solution. We are also running out of nurses and NP;s. I asked a Senate aide once who had told me congress wasn’t worried about the plummeting number of PCP physicians and not enough NP’s. He told me they would just be happy for pharmacist and regular nurses to do the work. When they were not enough, they had plans for the new “Medical Technicians” which would be high school graduates (or GED?) who had three months of technician training. He said we only dealt with about twenty diagnosis and they would give them a protocol for how to diagnose them and also what was the standard treatment. Now most of the time this will be OK. However this was three years ago before the present government takeover law. As for medical schools turning out more doctors, well they don’t have the money to add more slots. I guess with more taxes they can expand and get all those brilliant students that are now left out. Most of my doctor friends say they will retire, but for sure not take any of the new government patients. Hope everyone enjoys the new plan. Most of the time it won’t matter.
I don’t think it will be horrible for primary care. Doctors will have more competition and need to strengthen their caring skills. NPs will bring down the cost for general care.
My intuition is that an experienced NP may be far more effective than an inexperienced MD. Although some think of medicine as a “gift” I tend to think of it as a skill set, in the way Gawande, for example, discusses effective checklists. My general point: skills can be learned, and they’re often learned on the job and not just in a medical college.
I also wonder if as there are a dearth of medical generalists, NPs may be filling a void that the medical market is leaving.
Personally, more competition is better. Let people decide who they want to go to. If an NP sets up an everyday practice that is better than a doctor, bless her.
I’m glad I waited to see other responses before I wrote my own. There are a variety of valid points.
What troubles me, however, is that the NP will be subject to creeping credentialism, just as with many other careers. The “doctorate” was already mentioned. But if it need not be a medical doctorate, then what? Ph.D. in Postmodern Deconstruction? Ph.D. in Women’s Studies? Ph.D. in Medieval Military History? Ed.D.? (Don’t laugh at this last one: Some brand of cold medication advertises that it was created by a schoolteacher.) It’s only a matter of time before patients will seek out the “doctors” among the NPs.
I split my time between Florida and another state. The Florida community has a lot of retirees, and thus a lot of medical care providers, including NPs. I rather like the NPs. But in the past decade, I’ve noticed that the local community college (which used to provide 2-year certificates to medical support staff) has dropped the “community” label and now offers 4-year programs; a local private college, which formerly offered a 4-year degree, is now a “university” with graduate programs.
“If an NP sets up an everyday practice that is better than a doctor, bless her”.
Oh, maybe she can set it up, depending on the state, but good luck, ultimately, to all the patients…she truly does not have the training or the skill set for independent practice.