“Hey Nursie!” The Battle over Letting Nurse Practitioners Provide Primary Care

 Twenty-eight states are now engaged in a heated debate over the difference between a doctor and a nurse: Legislators in these states are considering whether they should let a nurse practitioner (NP) with an advanced degree provide primary care, without having an M.D. looking over her shoulder.  To say that the proposal has upset some physicians would be an understatement. Consider this comment on “Fierce HealthCare”:

 “An NP has mostly on the job training…they NEVER went to a formal hard-to-get into school like medical school,” wrote one doctor. “I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpinning principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive. HEY NURSIE, IF YOU WANT TO WORK LIKE A DOCTOR…THEN GET YOUR BUTT INTO MEDICAL SCHOOL AND THEN DO RESIDENCY FOR ANOTHER 3-4 YEARS. NO ONE IS PREVENTING YOU IF YOU COULD HACK IT!” [his emphasis]

Fortunately, not all physicians exhibit the same degree of rancor. Some support the movement. Another “Fierce HealthCare” reader notes the commenter’s emphasis on just how brutal med school  can be: “The anger reflected in the previous comments reveals not only the writers' ignorance of scholastic achievement required of Nurse Practitioners, but mainly their fear that NPs will not be under physicians' control…Many older doctors' schooling and experience was conducted in punitive ways, sacrificing self esteem. It seems that anything less, isn't sufficient.”

The American Medical Association (AMA) represents many members of the old guard, and is intent on protecting the guild.  In some statehouses, the Associated Press (AP) reports: “Doctors have shown up in white coats to testify against nurse practitioner bills. The AMA, which supported the national health care overhaul, says that a doctor should supervise an NP at all times and in all settings. Just because there is a doctor shortage, the AMA argues, is no reason to put nurses in charge and endanger patients.”

But others argue that Nurse Practitioners have the needed training and that, in fact, doctors who have gone through the full medical school curriculum are over-qualified for a job that, today, is more about coordinating care than medical science.                              

Who Are Nurse Practitioners?

This raises the question: just who are these nurse practitioners, and how skilled are they?  Nurse Practitioners are registered nurses with a graduate degree, usually a masters, though by 2015, a doctorate, or a DNP, in nursing practice will be the standard for all graduating nurse practitioners, says Polly Bednash, executive director of the American Association of Colleges of Nursing.

The profession sprang up in the 1960s, partially in response to a shortage of primary care physicians in rural areas. This was the decade when doctors began to specialize. (With the passage of Medicare legislation in 1965, suddenly there was more money on the table to pay specialists, and at the same time, medical knowledge was advancing at a breathtaking rate. More and more physicians wanted to become part of the well-paid vanguard, on the cutting edge of medical science.)

Today, the share of medical students who choose primary care continues to drop. Health care reformers hope that the legislation will reverse the trend by providing better compensation for primary care physicians, and by offering generous scholarships and loan forgiveness to med students who choose primary care.

This should definitely help. But if we are going address the needs of a population where chronic illness is now a much greater problem than acute diseases, we desperately need more primary care providers. Today, Managed HealthCare Executive reports, “nurse practitioners are the only healthcare professionals” who are pursuing primary care in “increasing numbers.”  

Although there are many NP specialties (such as acute care, gerontology, family health, neonatology, pediatrics and mental health), about 80% of NPs have chosen primary care.

We need health care providers who want to be on the front line of managing chronic disease. NPs don’t seem deterred by the relatively low pay. Wealth is relative: while NPs, like most professionals, would like raises, they are not comparing their incomes to the $450,000 that an orthopedic surgeon might bring home.

This may help explain why research shows that patient satisfaction is often higher among patients who see NPs. These days, many primary care docs are burned out— and if a doctor isn’t happy in his chosen profession, chances are his patients will sense his malaise.

Low morale among PCPs is understandable. As a post on the Yale Journal for Humanities in Medicine (YJHM) blog points out:   “Compared to other physicians, primary care doctors are at the bottom of the social order in the medical hierarchy. They are also among the lowest paid despite the many time-consuming tasks such as filling out insurance forms, drug refills, nursing home and hospital documents that must be read and acted on. These are in addition to the many coordinating responsibilities that they perform for their patients.

For most of these tasks, many primary care doctors are actually ‘over-qualified.’” YJHM continues. “Clearly, while they have taken on the role of health care ‘coordinators’ they have become more dependent on specialists to take care of the sickest patients. Their ‘scientific’ medical role has decreased while their ‘coordinating" role has increased. For many primary care physicians their medical training is of less importance in their new roles.

 “It is wrong to insinuate that nurse practitioners do not have the medical training necessary to perform some and even many of the tasks that primary care doctors now perform,” the YJHM blog concludes.

Let me be clear: not all primary care doctors spend most of their time coordinating care and referring patients to specialists. In parts of the country where there are fewer specialists, PCPs do more of the work of diagnosis and treatment themselves. In addition, many primary care physicians work in large mutli-specialty practices where they are far less likely to be immersed in paperwork; often they are actively involved in teaching patients to manage their own chronic diseases. But it is true that the internist working solo or in a small private practice in many cities often finds himself/herself mediating care rather than providing care.

As for nurse practitioners, as they become a growing force in the medical profession, morale among them is rising. Twenty-three states now credential nurse practitioners as primary care providers, and given the legislation under consideration in states nationwide, that number is bound to grow. Nurse practitioners are feeling empowered. In 1990 there were 30,000 NPs in the U.S.  Today there are 115,000 according to the American Academy of Nurse Practitioners (AANP). And they know that they can do everything a doctor does: take the patient’s clinical history, perform physical exams, diagnose disease, order and interpret laboratory radiographic and other diagnostic tests, and prescribe medications.

NPs can prescribe under their own signature in every state, although in four, including Florida and Alabama, they cannot prescribe controlled substances and narcotics. This can make pain management difficult.           

While NPs Earn Less, They Spend More Time with Patients

Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85% of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60. If these nurses provide primary care, this “saves money for the Medicare pro
gram,” Jan Towers, PhD, director of health policy for the American Association of Nurse Practitioners (AANP) points out.

In 2008, median pay for primary care doctors was $186,000 according to the American Medical Association, though some primary care docs make much less. Median income for nurse practitioners now averages $83,000 to $86,000.

Nurse practitioners also help rein in health care spending because they “advocate prevention and health promotion,” says Towers.  “As a result, there are multiple studies that show lower rates of emergency room visits and a lower number of hospital days by patients.” 

Going forward, I suspect that nurse practitioners will help run many of the new community clinics that reform legislation is funding. There, they will create the medical homes that newly insured low-income patients need, and help keep them out of ERs.

How will they do this?  Research published in BMJ suggests that NPs spend more time with patients than doctors do, and simultaneously, cut costs.  A study by Avorn and colleagues published in the Archives of Internal Medicine supports the thesis. The study used a sample of 501 physicians and 298 NPs who responded to a hypothetical scenario regarding a patient with epigastic pain (acute gastritis). The doctors and nurses were able to request additional information before recommending treatment. If they took an adequate history, the provider learned that the patient had ingested aspirin, coffee, and alcohol, and was under a great deal of psychosocial stress. Compared to NPs, the physician group was more likely to prescribe a medication without seeking the relevant history. NPs, in contrast, asked more questions, obtained a complete history, and were less likely to recommend prescription medications.

A 2004 study by Mundinger, Kane, and colleagues is now considered the most definitive research on the quality of NP care. It explored the outcomes of care in patients randomly assigned either to a physician or to a nurse practitioner for primary care after an emergency or urgent care visit. The NP practice had the same degree of independence as the physician: this made the study unique. After analyzing the services that patients used, and interviewing some 1,136 patients, the researchers determined that the health status of the NP patients and the physician patients were comparable at initial visits, 6 months, and 12 months. A follow-up study conducted two years later showed that patients confirmed continued comparable outcomes for the two groups of patients.

Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health rejects the argument that patients' health is put in jeopardy by nurse practitioners. “There's no evidence to support that,”  Needleman told the AP. “Other studies have shown that nurse practitioners are better at listening to patients. And they make good decisions about when to refer patients to doctors for more specialized care.”

Nurse Practitioner midwives also receive high marks. They attend 10% of all births in the U.S., 96 percent of which are in hospitals. A number of studies of low-to-moderate-risk women giving birth show that after controlling for all social and health risk factors, the risk of infant death with a nurse-midwife is as much as 19 percent lower, neonatal mortality as much as 3 percent lower, and low-birth-weight infants up to percent fewer than with physician-delivered babies. 

Other studies reveal lower rates of caesarian sections, as well as significantly fewer infant abrasions, perineal lacerations, and complications.

Researchers point out that it is possible that mothers who choose nurse practitioners to deliver their babies are healthier, or less inclined to want caesarians. But at least one study of high-risk mothers in an inner-city hospital suggested that midwives provide equally safe care in these more difficult cases. 

Some NPs point out that they must do better. As Chicago nurse practitioner Amanda Cockrell explained to the AP: “We're constantly having to prove ourselves.”

Medical evidence that NPs offer as good or better care threatens some physicians. “They're really scared that we're going to do something that will take money away from them. As long as we went out and only gave healthcare to poor people, nobody said anything,” Dee Swanson, president of the American Academy of Nurse Practitioners, told ModernHealthcare.com earlier this month. “Let's face it: We have a crisis in primary care in this country, and it's an area that physicians have not been interested in, or there wouldn't be a shortage.”

Some Insurers Balk at Paying NPs; Reformers Reward Them

Despite all of the convincing data about the quality of care that NPs provide, “Acceptance by health plans varies across the country," the AANP’s Towers told Managed Care Executive. "Some are fully onboard in certain parts of the country. But in other sections, health plans are still hesitant and require strings that we believe are unnecessary.

"Then there are cases where you work very well with a company, but there is a merger with a company that hasn't worked with nurse practitioners,” Towers adds. "You have to start all over again."

In California, where insurance plans do not recognize nurse practitioners, the state’s more than 10,000 NPs are beyond frustrated. Although private insurers pay for the services offered by NPs, they do so as if the NP’s collaborating physician provided the care. (This may give the insurer an opportunity to pay less for the same care.) 

In states where insurers shun NPs, patients are unable to name a nurse practitioner as their primary care provider, and this can lead to confusion. In addition, patients looking for a new primary care provider will only find physicians listed in their insurance company web sites and printed materials, even if well-trained nurse practitioners are available to serve them. (I can’t help but wonder, have these insurers succumbed to pressure from physician lobbies?)

When reform legislation kicks in and millions of formerly uninsured Americans begin to look for a PCP, many patients won’t be able to find a provider in California—unless the law changes.

This is one reason why the Josiah Macy Jr. Foundation, which funds programs designed to improve the education of health care professionals, ong>recently recommended that regulators immediately act to remove legal and reimbursement barriers preventing nurse practitioners from providing primary care, and to empower them to lead multidisciplinary teams of primary-care providers. Dozens of health care organizations signed the report; the AMA was not among them, but the American College of Physicians was.

The Foundation’s proposal that nurse practitioners should manage health care organizations upsets some physicians. If NPs ran community clinics, they might supervise doctors, and even oversee programs training residents in primary care. "I would never want to see the nurse leading the team in a patient-centered medical home," Dr. James King, President of the American Academy of Family Physicians, said in 2008.

But the times are changing. Unlike some insurers, legislators who crafted health reform legislation seem to have paid attention to the research on quality. They are offering the same financial incentives to nurse practitioners that they offer to physicians:

10% bonuses from Medicare from 2011-16 to primary care providers, including nurse practitioners

• $50 million to nurse-managed health clinics that offer primary care to low-income patients.

• $50 million annually from 2012-15 for hospitals to train nurses with advanced degrees to care for Medicare patients.

Moreover—and here’s the surprise—the legislation boosts the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor's.                              

A Nurse’s Training– It’s Not the Same

These days, nurse practitioners are spending more time in school. For example, on top of four years in nursing school, Chicago NP Amanda Cockrell spent another three years in a nurse practitioner program, much of it working with patients.

By 2015, the American Association of Colleges of Nursing will require its approximately 200 members to offer a Ph.D. Johns Hopkins already has rolled out a forward-looking graduate program for nurse practitioners that focuses on evidence-based medicine.

But even while nurse practitioners put more years into education, both supporters and critics agree: the training is not the same.

Daniel Lucky of Modesto, Calif., an NP adjunct nursing lecturer with University of Southern Indiana and adjunct faculty for Indiana State University, says that nurse practitioners take a different approach:  "NP practice is based on the nursing model of care–not the medical model," he wrote in a commentary for the Evansville Courier Press. "Nursing teaches us that we should not reduce human beings to mere signs and symptoms, place a disease label on someone, give them a pill and send them off. As nurses we are trained to look at the entire patient from a holistic perspective and then, actively partner with the patient and family to not only correct problems, but also enhance optimal health. Nursing care places the patient–not the provider–as the central focal point.”

Critics put it differently: Texas physician Gary Floyd opposes giving nurse practitioners too much autonomy by arguing that “Nursing schools push a ‘care and comfort’ approach to giving care.”  Floyd, who serves on the Texas Medical Association's Council on Legislation, contrasts training in “comfort and care” to “the scientific perspective of medical schools that teach about disease processes and bodily interactions.” 

Here, I have to differ. As a patient, I’m a big fan of “comfort and care.”  Not all diseases can be cured. If I were suffering from a curable disease, I would trust the vast majority of nurse practitioners to refer me to a specialist who might know how to conquer the disease. Otherwise, I would like to stick with the provider who focuses on talking to me, listening to me, comforting me, and making sure that I’m not in pain. 
Health care reform means that we need to re-think medical school education. We don’t want to continue to train young doctors to fit into a system that we know is dysfunctional. Many medical educators suggest that we are making students take science courses that will be of little help when they actually practice medicine. Depending on his or her specialty, not all physicians need the same in-depth understanding of body chemistry or anatomy. Students are forced to memorize information that may well change as medical science evolves over the next five or ten years. When they are treating patients, they will look up the newest information on best practice, or the ideal dosage for patients who fit a particular medical profile,

In a 21st century medical school, many argue, students need more training in patient-centered medicine: how to educate patients so that they can collaborate in managing chronic diseases; how to share decision making with patients; how to manage pain;  how to tailor end-of-life care with an eye  to the individual patient’s greatest desires and worst fears.

 Don Berwick, President Obama’s candidate to head the Centers for Medicare and Medicaid, defines patient-centered care in a way that sounds much closer to the nursing school model. Berwick argues that it’s all about asking the patient: “What do you want and need?" "What is your way?" "How am I doing at meeting your needs?" "How could I do that better?" "How can I help you?"

Isn’t that what nurses—and even doctors—once asked? 

56 thoughts on ““Hey Nursie!” The Battle over Letting Nurse Practitioners Provide Primary Care

  1. We recently issued a report on the future of primary care from an Arizona perspective. This included a variety of interviews and focus groups with both docs and NPs working in primary care, among others.
    Arizona is a state where NPs are able to practice and prescribe independently. Among the NPs we talked to, there was a split between those who were more comfortable working with, and under the direction of, a physician, and those who practiced independently (some solo, some in nurse-run clinics) and expressed a fair amount of anger at getting paid less than docs for doing the same work. There is more diversity on this issue in the field among working NPs than there apparently is in the nursing schools, which have a vested interest in upgrading degrees and attracting more students. You can read the two-part “Goodbye, Hello” report at http://www.slhi.org.

  2. Maggie,
    The supposed ability of nurse practitioners to deliver primary care services highlights what I had proposed to you in earlier posts; that being that the educational system needs to be reformed to provide the level of training needed for a physician or nurse practitioner to deliver the service. We had argued previously about cutting the years of undergraduate study before application to medical school as a way to reduce educational costs, which you had soundly rejected. But as a primary care doc, what this piece is telling me is that we can acheive the same level of competency in six years instead of requiring 8 years of post graduate training and 3 years of residency. These extra years of cost and training, as well as time, are what drives medical students away from primary care. The secondary education system is more resistant to change and I would argue, more costly than it needs to be.
    Secondly, the whole payment system is what has driven priamry care docs to become coordinators of care. Due to low payments for office visits that do not give enough time to ask all the pertinent questions that need to be asked, it becomes more economical to identify the problem, and turf to the specialist. This works to PCP and specialist advantage, since specialists wil tend to back refer to the PCPs who refer them the most buisiness. What this has done is to dumb down the primary care position to one that can be very unsatisfying, and which opens up the idea that nurse practitioners can perform all the duties of a primary care doc! If primary care is truley practiced the way it was intended, then this idea equivalence between NPS and PCPs would not exist. If we want to persist in having an expensive medical system top heavy with specialists, then it would be the right thing to do to have lower level nurse practitioners perform all the tasks and refer to specialists more frequently. What I would argue is that it is this rigged system that has made the primary care doc nothing but a referral machine in many parts of the country, and that it is a reorganization of the reimbursement system, and possibly introduction of the medical home model that is necesary to offer better quality primary care.
    I would also question the idea that nurse practitioners will overall save the medical system money. Most still function under the auspices of a supervising MD and are not always willing to take call and work off hours. If they work under and MDs supervision, their malpractice costs are close to nothing (they sue the supervising doc, not the NP), but what happens once an NP is independent? Indeed, if nurse practitioner can charge the same as an MD, where wil the cost savings generate from? Recognise that the duties of a priamry care doc encompass many uncompensated activities. Will the indepentdent NP perform all these activities if not collecting their hourly compensation? It may be the fact that many NPs have fixed hours without the need to crank patients through their office that makes them more relaxed and willing to spend time with a patient. If placed in the same situation as the PCP, will they behave in the same manner? Once they have to pay the malpractice, the receptionist, the billing company, etc., etc, will their practice style remain the same? Unless your referenced study looked at NP and PCP in the same practice situation, they are not comparitive studies in my opinion and thus, not very helpful to see if nurse practitioner can do the same tasks at a cheaper price

  3. Will this mean they will have Cardiology NP reading the Echos, Treadmills, Pulmonology NP doing brochoscopy? That makes more sense than Primary care NP. I will submit that procedures when done over and over again will ‘almost” give the operator the expertise but cognitive medicine where you see a patient with memory decline, general fatigue, deciding between antibiotics or water pill needs vast expertise otherwise overtreatments and uncessary treatments will be norm. Another tricky issue will be liability, if the buck stops at NP, then will see sky rocketing referrals and over treatments much, much more than what we have. There are great NPs but over treatments will become standard if they are doing primary care, I will bet my last penny on this.

    • Absolutely right. NP’s will lead to overutilization. They are also extremly poor at coordinating care with consultants and assuming an overall care plan. Their mentality is see symptom, treat symptom. Sorry, inferior training from an inferior talent pool doesn’t get you better results. They will go the way of the LVN or become scutt monkies as time goes on.

  4. Ray, Keith, Roger
    Ray –What we have found is less over-treatment when NPs are providing care.
    Fewer Ceasarians. Less likely to prescribe medication. Lower overall costs because they are less aggressive.
    (We also see notably fewer malpractice suits when NPS are practicing alone than when docs are providing the care.–I’ll get back to that in a minute.)
    Why do nurses provide less aggressive care? I’m told it’s a difference in the training. In med school, students, interns and residents are taught: “Don’t just sit there, do something!” Run a test. Run 5 tests. Before we had the tests they used to go in and “do some exploratory surgery–it can’t hurt.”
    In med school, traditionally, students are taught that the best doctor is “thorough.” And the goal is to “cure” the patient. Death is the enemy. Pull out all the stops. Save the patient.
    In nursing school, there is much more emphasis on comfort and care (rather than just cure). Also, much more emphasis on
    listening to the patient. Taking the time to do the history right– and get the full story.
    This is why NPs spend more time with patients.
    I also remember Dr. Diane Meier (a palliative care physician) talking about how, often, the best thing you can do for a dying patient is just to sit there by his side. Be there. Hold his hand. She noted that this is a very, very difficult thing for most doctors to do. Nurses are better at it–because they are trained to “comfort” to be a silent witness if that’s all that can be done.
    There may be a gender difference in all of this since traditionally, most nurses were women. But today, many more men are nurses. Though I would suspect the profession doesn’t attract as many Type A super aggressive males as some branches of medicine . . .
    Why are NPs sued less often? I can think of several reasons. First, if they tend to practice more conservative medicine (“doing less”) they are less likely to hurt patients. Secondly, all of the research shows that patients are more likely to sue if they found the doctor cold and arrogant from the very beginning. I would submit that few truly cold and arrogant people are likely to choose nursing as a profession (It’s a service job– arrogant people are not enthusiastic about serving others. Of course, Don Berwick would point out that being a doctor is also all about serving –and “the joy of serving”, but many people don’t think of it that way.
    Finally, on the question of what it takes to diagnose and treat “a patient with memory decline, general fatigue . .” You say “deciding between antibiotics or water pill needs vast expertise”
    Everything I have learned about medicine from doctors suggests that this is exactly the sort of situation where experiential knowledge is most important. Not what you memorized in science classes in med school, but rather a combination of conscious and unconscious knowledge that is all tied up with observing patients– how they look, sounds, smell, feel– body language, etc.
    A number of years ago, my husband accidentally cut his finger off–he arrived at the hand surgeon’s office with a two inch piece of finger wrapped in a cloth.
    First, a young surgeon looked at it, shook his head, said nothing could be done. The finger had to
    be amputated. There weren’t enough nerves (or whatever) to sew together.
    I prevailed on the senior (famous) hand surgeon to look at it as well. He was probably 70. He took my husband’s finger in his hand and smelled the cut end–much the way I might smell the roots of a plant before planting, to make sure it’s healthy, not rotting.
    He said “It will be fine.”
    Then, after anesthetizing the hand, he attached the piece to the rest of the finger with a spike that he drove down the center of the finger.
    It healed perfectly. The nail grew back. It looks fine and my husband has full use of his finger.
    Bottom line: the older surgeon had experiential knowledge, not book knowledge. And at some point in the past (probably a number of times) he had used the spike rather than sewing the finger together.
    You’re right that primary care is difficult because docs are often dealing with great ambiguity, more than one chronic decision, an older patient who is forgetful.
    But the health care provider who actually listens to the patient, looks at her, touches her is more likely to get the diagnosis right.
    Keith–
    You’re missing the point: NPs with a Ph.D. go to school for 8 years. This is not about less education, it’s about a different kind of education. (See my response to Ray above.)
    Less science, more emphasis on palliative care, interpersonal communication, understanding what your patient is feeling, the patient as a whole human being (not just a diseased body part), helping your patient manage her own chronic diseases.
    (A background in the humanities–which many nurses have– would be helpful.)
    It’s less provider-centered, and more patient-centered. (I would expect that medical education may also begin to go in that direction, and we’ll see more NPs and primary care docs being trained together.
    Secondly, the NPS who work alone (without a doctor) are not “referral machines.” Most often they work in rural areas where there are few doctors. They do everything–diagnose, and treat, without specialists. There are much more like old-fashioned general internists and just as able to do this as an MD.
    They may also be more willing to work in poor rural areas because they went into nursing to help people–not to become partof a profession where they could count on a certain “lifestyle.”
    In terms of whether they will help bring down costs: Today about 15% of NPs are in private practice. It’s not at all clear that they want to run a small business or be “entrepreneurs.”
    Unlike some physicians, they don’t see medicine as a business but rather as a “caring profession.”
    So they’re not likely to wind up paying their own malpractice insurance, hiring receptionists, etc. etc.
    The small practice model is a very inefficient way to deliver health care–no economies of scale. Which is why there are likely to be fewer and fewer small to medium-sized practices (except in thinly populated rural areas) going forward.
    NPs who work in communtiy clincis or large multi-specialty organizations will enjoy the support such organizations offer (back office, etc.)and rather than running a business, can focus full-time on caring for patients. This is the future (for NPs as well as for Docs)
    Since they were never part of the physician income ladder (which has taken some specialists’ salaries to heights that society cannot afford) nurses are not expecting to make $500,000 a year.
    Looking ahead, I would suspect that NPs, like the lowest paid primary care docs will continue to get pay hikes, but that utimately income for primary care will level off at, say $125,000 to $160,000 (in today’s dollars.)–up from the $80,000 to $90,000 NP’s make today.
    And that as NP going into other specialties (ObGYN, radiology, orthopedics) they will never charge as much as the most expensive specialists do today.
    Specialists’ salaries get way out of whack because they began comparing themselves to ridiculously over-paid CEOs.
    In some specialties, NPs may well end up earning what modestly/reasonably paid specialists make.
    But if NPs replace MDs in some areas, this will be one way to address the over-payment in the top half or top third of the physician income ladder.
    It looks to me that this is what legislators had in mind by providing financial incentives for NPS . . ..
    Roger– Thanks for trying to send me the link.
    But when I clicked on “Hello Goodbye- The future of primary care” –
    I didn’t seem to find anything on NPs.
    First, there was a couple of pages on webs, spiders, E.B. White. Then many pages on community, weaving, etc.
    A lot of quotes.
    I couldn’t find anything about a survey of NPs.
    IF I could make a suggestion: the site seemed “over-produced”–attractive, artistic, poetic, but not user friendly for someone trying to do research. . .
    My own sense is that some NPS will want to work with docs; some won’t. Each model will work, in different settings, and in different regions of the country.
    Since NPs are already important to community clinics and since reform is funding so many more clinics I suspect they will be both staffing and running many of them.
    I also think the solo or small practice of docs with one NP will become less common in most of the country simply because the economics don’t work.

  5. I think there’s enough work for all of us in primary care and I think NPs and PAs are vital to meeting the demand.
    I do find myself pushing back against the idea that an NP is as qualified as I am to care for patients, but that mostly comes from me wondering why I went to 4 grueling years of med school & 3 grueling years of residency if I’m no better at my job than someone with far fewer training hours. But it doesn’t come from any reasoned perspective, it’s mostly jealousy for all those years lost (weddings, bar mitzvahs, family reunions, etc that I couldn’t go to) and all that debt yet to be repaid!

  6. I’ve been working with NP’s and PA’s for 30 years and don’t feel threatened by it. They are well-trained, professional, compassionate, and deliver high quality care. They operate within a scope of practice (as do we all). I agree that some were more comfortable working with a physician–sometimes it’s just the value of bouncing thoughts off of one another (physicians do likewise, just less visibly). Others felt confident, and were quite capable, of working independently. They are a partial answer to access issues we will face over the next 10 years, but I’m dubious that cranking up medical, NP, and PA schools to produce more will be sufficient. Also, I don’t agree with some of the opinions here about nursing models (I was taught the same things in medical school), time spent, more caring, rural willingness, etc. I find those things to be a function of the individual’s style, practice requirements, and interpersonal skills, not the training or profession.

  7. Sharon MD & Susan
    Sharon Good to hear from you–and thanks for the candor!
    You’re right there is plenty of work in primary care. Physicians don’t have to be worried about being driven out of the business. (My guess is that the AMA is more worried about NPs going into other more lucrative specialties.)
    You are right that NPs undergo fewer hours of training –but they don’t necessarily undergo fewer years of training. The problem with medical training, I think, is that it’s unnecessarily grueling. I’ll get back to that.
    But keep in mind that the NP with a masters’ who I described spent 4 years in nursing school, then 3 years getting the master’s.
    Those with a ph.d. spend 4 plus 4 for a total of 8 years.
    Then, when they begin practicing the vast majority probably work with an M.D. first — so that’s not unlike residency. They are apprentices. (When I was reading about NPs a couple of people said that it is ideal if they work in a big city hospital for a few years before trying to practice independently. Makes sense.)
    That said, from what I have heard from young doctors and medical educators, it does seem that there are many courses in med school that are not necessary for all specialties. (Or, in some cases, any specialties.) They are required simply because they have always been required.
    Now that we have reform, most people understand that we also need to re-think medical education, We don’t want to train people for the old broken system.
    But people also tell me that there are many courses that are not required today that should be: Palliative Care (a course on death and dying) the Economics of Health Care (the physician as steward of health care resources?); Pain Management (this could be part of palliative, or a separate course) Comparative Effectiveness Research; Cultural Competence; Collaboration a course or courses where med students, nurses, physical therapists train together, . . . Those are just a few ideas off the top of my head.
    These courses would replace some of the science courses which ask med students to memorize facts that a)may well change over time and b)they can look up when actually practicing medicine.
    So I’m not convinced that training would require fewer years– maybe one year..
    I also think that docs need to grow up before being unleashed on sick people. Your average 25 or 26-year old is just too self-absorbed, too narcissistic, too lacking in empathy for the elderly, too likely to over-react . . .
    I say this about 25-year-olds who I like.
    It’s just that most people mature between 24 and, say 29; it seems to me a crucial period in the process, at least for 21st century Americans. (Years ago, of course, people grew up much earlier.)
    But as I said, I don’t think those years of medical training need to be so grueling.
    All of the “hazing”–long hours, bullying, emphasis on memorizing material for tests, being asked questions and ridiculed if you don’t know the answers . .
    This just strikes me as evidence that originally, most doctors were men, and men with a real “Lord of the Flies” mentality managed to take over the medical schools.
    This definitely should change. Yes, doctors need stamina, but I don’t want a doctor who has been working for 12 hours caring for me. I would rather be “handed off.” (And med schools need to focus on teaching the hand off.)
    If you hadn’t been working such long hours, you probably could have arranged to go to some of the Bar Mitzvah’s and famly reunions–and been a better, happier person as a result.
    I think the whole “boot camp” mentality turns some doctors into pretty angry, overbearing, “my way or the highway” people.
    Those years in med school should be about learning to nurture, not about learning to take physical and mental abuse.
    Susan– Given what you say about not liking all of this “feeling, ” “smelling” etc. I’m glad you’re not a primary care provider!
    Seriously, why is $500,000 not too much for a pathologist? Why not $700,000? Or $250,000?
    Why should pathologists earn so much more than palliative care specialists, or general surgeons?
    Or perhaps all doctors should be paid a minimum of $500,000. But how could society afford that?
    Do you think that fewer people would go into medicine if they knew that, mid-career, they wouldn’t earn more than $250,000 or $300,000?
    Do you think the people who chose not to go into medicine for that reason would be missed?
    If we subsidized med school, many more qualified candidates would apply. . . And if U.S. doctors were paid salaries comparable to European doctors, we could afford to subsidize medical school, and still wind up with a lower national health bill.
    Would that be so terrible?
    (for society as a whole)?

  8. I think 250,000 is also fine for a pathologist and I think many fine people would go into medicine for that amount. The group I am in just tends to do better. For the amount of responsibility that pathologist’s have (people tend to lose organs by what we say) I see nothing wrong with being paid quite well.
    General surgeons on average make more than a pathologist.
    I don’t think medical school needs to be subsidized to get more qualified candidates. Once an individual gets accepted to medical school the banks will throw money at you. There is no need to worry about paying for it, but there is worry about paying it back. I know many dirt poor qualified individuals who got accepted to medical school–you don’t have to be affluent to get in. Unfortunately, those from poor backgrounds do not want to go back to their origins to practice medicine. Once they get out there is nothing in the rear view mirror. Just like FMG’s–they too do not want to return to their country of origin.
    At least we agree that I do not belong in primary care.

  9. Doc D–
    Thanks for the comment.
    You write: “They operate within a scope of practice (as do we all). I agree that some were more comfortable working with a physician–sometimes it’s just the value of bouncing thoughts off of one another (physicians do likewise, just less visibly). Others felt confident, and were quite capable, of working independently.”
    Thank you–so well put.
    As for whether we can meet the need for primary care providers by increasing the number of primary care providers that we graduate from med schools and nursing schools—I really think we can.
    When it comes to med schools, we need to enlarge the pool of students who apply. Right now very few students apply to med school who are not coming form relatively wealthy or at least high-end upper-middle-class families.
    The cost of med school is just too high. Middle-class and lower-income students can’t even imagine taking on that much debt. (And if they get into financial trouble, get sick, get married and have a sick child, realize that they don’t want to pursue medicine and want to quite med school– they know their families can’t bail them out.)
    But reform legislation greatly increases funding for scholarships and loan forgiveness for low-income students. (The funding is comparable to what students had in the 1970s.)
    Meanwhile, research shows that students coming from low-income families are much more likely to want to go into primary care, and to work in an inner city or a poor rural area, like the place where they grew up. As some put it, they want to “give back.”
    As for nursing schools, in recent years many qualified candidates have been turned away because there just weren’t enough nursing school teachers. They were underpaid– paid less than nurses outside of academia.
    Again,the reform legislation has addressed that problem, boosting their salaries, which should mean those nursing shcools will be able to take more of those qualified candidates.
    I don’t think this country needs more doctors. On the whole (in most regions and in most specialties) we have enough, or even more than enough specialists.
    But we do need more primary care providers, and I think they’re out there, eager to do the job.
    As for what docs & nurses learn during their training. You write: “I don’t agree with some of the opinions here about nursing models (I was taught the same things in medical school), time spent, more caring, rural willingness, etc. I find those things to be a function of the individual’s style, practice requirements, and interpersonal skills, not the training or profession.”
    Point taken. I know a fair number of physicians who come out of med school focused on “comfort and care” not just cure. And this is all tied up with who they are, not how they were trained.
    That said, much also depends on where and when you went to med school.
    You indicate that you have been working with NPs for 30 years, which means that you graduated from med school before 1980.
    1980 would turn out to be a turning point for medical culture in this country. See Paul Starr’s wonderful “The Cultural Transformation of American Medicine.” Published in the early 1980s, it earned a well-deserved Pulitzer.
    I summarize what Starr says at the begining of my book (Money-Driven Medicine) which traces the history of how medicine became “corporate” and money-driven, just as Starr predicted it would when he was writing in the early 1980s. See the end of his book. He hoped he was wrong.
    So you may have gone to med school at a time when there was more emphasis on the notion that medicine is about serving the patient, caring for the patient, putting the patient first.
    Less emphasis on medicine as a business, the doctor as entrepreneur.
    Secondly, this is regional.
    I have spent my entire life in the Northeast and most of the doctors I know went to med school here.
    They describe a med school education that did not encourage them to consider practicing in a rural area, spending more time with patients etc. They were taught to aim for the top.
    When I began writing my book, I began to get to know docs in other parts of the country. I disovered that medical culture– including Med school culture– varies widely depending on where you train.

  10. Maggie,
    Thanks for your thoughtful reply. I would offer that, although I’m hopeful about incentivizing primary care, when I was in school there were several students on scholarship to return to their communities, and a few more who expressed a desire to return. I know of two brothers who headed back to the Rio Grande valley (guess where I’m from.) The rest were either seduced by the “medical center” allure, or did the minimum time back home that they had to, before returning to the big city. The policy changes you describe will jump-start the process, but there has to be a cultural change also–just restricting access to specialties, or bumping up income (money doesn’t overcome the lack of respect–you’ve heard the term LMD, right?), might create some unhappy campers out in the boonies.
    You’re right–I graduated in 75. I spent 15 yrs fulltime ER/FP. Then 15 yrs in policy development/management/hospital CEO. My last big job was re-building a medical center destroyed by Katrina. I am part way through your book already (and enjoying it), and I read Starr way back when, but the research I was doing then was on medical anthropology and it was not central.
    With regard to his work and yours, I came at the end of the monlithic, AMA-driven years. The first malpractice crisis occurred during my residency, and there was talk of dropping us from the Baylor/Ben Taub policy. Very scary at the time.
    D

  11. Maggie,
    Excellent post, agree with most of it. I’d suggest that we need a better balance for the NP-educated patient-centered comfort model and the medical school science model. Effective triage, or care coordination, still needs to be based on science. But its still a different focus than the current 4 year med school curriculum and 3 year residency that currently applies. Primary care should have a different track than specialty care– and both need significant medical education reforms. However, simply moving to the ‘care and comfort’ approach for what is the frontline of medicine is overshooting too far. Effective, value-based medicine needs to be based on robust data and scientific assessment. The patient centered approach is as much about helping less educated patients understand the data and resulting tradeoffs, as it is about care and comfort.

  12. A little reality therapy from a frontline family doc: Right now medical students are making up their minds about specialty choices. My concern is that, in the long run, even more of them will think that going into primary care medicine is a dead end job. If NPs are just as good as they are, then why the heck should health systems (who will be controlling things in the future) pay them any more and treat them any better than they treat the NPs? And sure, there are plenty of jobs now, but what about 10 or 20 years down the road, when lots more NPs are trained up? Maybe it’s better to subspecialize. Check that. It’s certainly better to subspecialize.
    Also, some have called for a collaborative model, in which an MD provides clinical backup to a group of NPs, who see most of the pts. But the devil is in the details, and I have done that job. It is a crappy job. Why? Because I’m not sitting around waiting for challenging cases. I’m seeing all of the most complicated pts in the clinic, plus consulting and/or taking over the pts that the NPs don’t feel comfortable with. Two jobs in one, for the price of one. I don’t recommend it. Med students (whom I precept)are aghast.
    But wait. It might get worse. With the PCMH concept, we docs will be responsible 24/7 (and the NPs don’t take call at my job), will provide clinical consultation for difficult cases for the NPs, have our own full schedules of all the most difficult pts in the practice, and be middle managers beholden to a private or public payer, all for much less than we could earn reading slides in the basement as a pathologist or passing gas in the OR, or being a concierge doc.
    The problem, in a nutshell, is that the coming restructuring of primary care might make it even more toxic to med students than it already is. Then if the NP has a question, they’ll be no one to turn to except the subspecialist.
    I really don’t know what will happen to primary care in the next decade or two. But my best guess is that medicine will chuck it to the midlevels, if they’ll take it. They’ll be a few medical hardcores and some concierge docs for the wealthy. And of course there might be an enormous overall shortage of PC “providers” if the docs leave the field.

  13. Dear Ms. Mahar,
    Great article, and thank you for your thoughtful and non-biased comments on the NP profession. It is refreshing for sure these days.
    Removing organized medicine’s strangle hold over the NP profession will have many positive benefits, not the least of which will result in increasing access to care for patients. It is important to remember, however, that individual physicians are not the villains in blocking NP advancement or independence.
    The real culprit here is organized medicine (AMA and state medical associations) and select individuals in the profession of medicine who champion advancing their own interests in the form of control, power and profits over patient access to care. It’s noteworthy that the vast majority of physicians support NP advancement just like the vast majority (81%) of physicians do not belong to, or will have anything to do with the AMA.
    All of the anti-independent NP practice AMA-based arguments flow into one central theme and concept. The rhetoric from the AMA essentially maintains that NP’s are not, and cannot be “competent” to practice safely in the absence of physician oversight, control and supervision. Competence, as a concept, is discrete in nature and differs significantly from continuum-based terms such as education, training and experience. In other words, education, training and experience are relative and exist somewhere on a continuum whereas one is either competent or not competent. In its discrete form, one cannot be a “little bit competent” anymore than someone can be a “little bit dead.” One is either competent to practice or not.
    Organized medicine is glad to have NP’s working for physicians because in this context, we are competent. The AMA vehemently opposes, however, NP’s working independently, because at this point we are no longer “competent.” Curious enough, and based on this logic, there is a strong and linear relationship between advancing the economic interest of physicians through NP practice and the presence of NP competence. For an organization that claims to be guided by “evidence-based medicine” one might think that logic would figure largely in guiding their thought processes. Sadly, this is not the case.
    Again, great article and thanks for sharing my quote from one my Op Ed’s.
    DLucky, FNP
    Modesto, Calif

  14. Where I work we have incompetent nurses enrolled in the NP program (I’m a nurse). Can’t speak for the curriculum in the local NP progrmm, but the entrance requirements sure don’t impress me.

  15. Doc D–
    Glad you’re enjoying the book — and congratulations for responding to Katrina.
    I understand that not all students coming from low-income families want to go back to their communities,
    but they are far more likely to want to go into FP –and to want to practice in rural areas–if they come from rural areas. These are the people we need to actively recruit.
    We actually have some good data on family background and choice of family practice/primary care.
    See this study on “Birth Origins and Family Practice Choice” http://www.unmc.edu/Community/ruralmeded/birth_origins_and_fp_choice.htm
    Students from high-income urban areas are least likely to choose family practice.
    These students tend to have higher MCAT scores; they attend more presitigious universities and are more likely to take expensive courses to prepare for the MCAT. Their parents have higher levels of income, and education.
    Students born in rural areas, Mexican-Americans students, students of all races born on a military base and older students of all races (over 30 at graduation) are more likley to choose family practice. Low-income students of all races are more likely to choose FP.
    Specifically, a large study of med students form 1994 to 2000 shows that only 14.6% of high-ncome urban students choose family practice or general practice.
    By contrast, 25.7% of students born in rural areas (and generally lower income) chose family practice/ general practice.
    The more sparsely populated the areas (which usually means poorer), the more likely they were to choose FP. A whopping 75% of those from areas with less than 50 pop per square mile selected FP. And 37% of those coming from aras with less than 250 pop per square mile chose FP. ( Unfortunately, only 14% of all students admitted to med school fall into this caregory– and the percentage is dropping each year. )
    19% of Mexican American Med students choose FP– compared to 14% of white students. But those white students who do choose family practice are likely to choose to work in rural areas –26%–which suggests they are coming from rural areas.
    47% of Native American students who choose FP chose rural areas– presumably this is where they grew up.
    13% of Black students choose family practice, but only 11% choose rural settings- they are more likely to go to urban areas, often inner-cities.
    Low-income blacks are far more likely to choose FP than high-income blacks.The percentage of Blacks choose FP has been falling in recent years which, the report notes, “suggests that fewer low-income blacks are going to med school.” This is in part because scholarships have fallen in recent years (post Reagan) and affirmative action has fallen out of favor.
    “Regardless of ethnicity, those with the most urban origins, the highest parent education and income levels, and the most college preparation are the least likely to choose family medicine and rural locations.”
    19.8% of students born on a miltiary base choose family practice/ general practice (again, tend to be low-income middle-income compared to vast majority of med students combing from high-income famlies densely popoulated urban areas.
    Only 14.8% of students younger than 30 when they graduated from med school chose family practice gen practice. They younger they were, the less likely they were to choose FOP. The more mature students were far more likley to choose FP. (22% of those 33 to 36.)
    Each year, more and more high income students are admitted to med schools while the percentage of students from low-income families continues to fall.
    “From 1997 to the 2001 entering classes in allopathic medical schools, the highest income level students increased at 700 a year while the lowest income quartile decreased at 432 a year.”
    The report points out that given the high cost of applying to med school, not to mention the cost of med school itself “Tragically many low-income students don’t even bother to apply.”
    Reform legislation makes a special effort to change the trend. Funding for scholarships for low-income students and both scholarships and loan forgiveness for students who chose family practice/ general pratice in underserved areas is very generous. (For the last 30 years that funding has been skimpy.)
    And more schools are recognizing that if they SLIGHTLY lower MCAT and GPA requirements, they will attract a wider pool of students, including many more low-income students.
    I wrote about this here :
    http://www.healthbeatblog.com/2009/05/reinventing-the-way-we-train-doctors-and-nurses-.html (See final section of post.)
    (When it comes to clinical work, these students score just as well as high-income students in med school. But generally they are not as good at taking tests–not as well trained in taking tests as students who often took a number of courses to prepare for SATs, MCATs, etc and went to schools where there was a strong emphasis on test-taking all the way back to junior high.

  16. Okay, so I had my first post deleted. Too curt perhaps. Here’s what I said in an expanded version.
    I’m a nurse with 17yrs experience, mostly emergency. Where I work we have recently started a SORT program to quicky see and treat the truely non-emergency complaints. This area is run by midlevels – NPs and PAs – but every pt is screened by a board certified Ed phycisian. It works very well and the NPs and PAs are a terrific addition to our staff.
    My personal feeling is that NPs can, will and should help fill the void of PCPs in our system.
    However – the prospect of higher wages have caught the attention of several of our staff nurses and we currently have no less than 8 of them enrolled in an NP program – about one third of our nursing staff. I’m sure that this is not typical. But the notion of NPs being drawn from the highly competent, experienced and engaged slice of the nursing profession, as they were just a few years ago, does not ring true to me in the present. Their is a local program that will, as far as I can tell, enroll any nurse with the desire to persue the NP designation, regardless of their level of proficiency or experience or engagement with their current role as a staff RN, let alone with the health care profession in general. It seems to me – and yes this is anecdotal – that the overall talent of newly minted NPs is poised to suffer a decline if this is a trend that extends beyond my personal experience.
    Some NPs that I know well are brilliant, and could no doubt operate with autonomy in a primary care setting. And I would have no resrvations sending a family member with a chronic condition to thier care. But the designation in and of itself does not confer this apon every, or, I would say, most graduates of the NP program, at least not locally (I live and work in Baton Rouge, Louisiana). The standards are just not high enough.

  17. I teach in an NP program. To those who question NP program requirements, it is true, you may have people who enter programs just barely meet the entrance requirements. But please be assured that the NP curriculum is a very, very difficult one. Marginal students don’t make it through. It is possible to flunk a graduate school course – either academically or clinically. I have flunked students for either reason. Believe me, none of us want incompetent NP’s practicing. We especially don’t want them to have graduated from our program. We have pride and ethics in our work and profession. Have a little confidence and trust in your colleagues.

  18. RE: The small practice model is a very inefficient way to deliver health care–no economies of scale. Which is why there are likely to be fewer and fewer small to medium-sized practices (except in thinly populated rural areas) going forward. (Maggie’s comment above.)
    I would submit that in your book of “Money Making Medicine” that you demonstrated that many corporate medical structures on large scale do NOT give economies of scale.
    Solo and small practices indeed continue to provide very cost effective care by providing more continuity, access and less duplication of services.
    As a solo, with staff privileges at a local hospital, I find myself best able to coordinate care; indeed, outcomes research of cardiac patients show a geometrical improvement of care when a specialist AND a primary care physician both care for patients.
    Continuity of primary clinical care with access to specialists continues to be the best model as shown in England and other European models; do not count out the value of primary care.
    Still it irks me that you feel the corporatization of medicine is the best model of care.
    I tell patients (I’m in my 25th year of family practice, last 6 years as a solo) that for chronic care, it’s better for them to make a hamburger in 7.5 ave minutes for an appt, and I’ll reserve the 20-30 minutes a visit for patient care.
    And yes, the experiential care of that 70 year old hand surgeon in the prior note does count for something — don’t count out us “older” solo family medicine and other primary care docs, exchanging us for NPs and PAs with limited clinical experience.
    Dr Matlev, solo in Western PA

  19. Jackytar–
    I would never delete a post because it was curt–or even rude.
    I usually reply to rude posts, point out that the style is not welcome on HealthBeat and that the commenter might want to find another blog.
    The only posts that are deleted on HealthBeat are clearly spammers selling something: Generic Viag__
    Coac_ Handba– etc. etc. etc.
    But we have had some trouble with Typepad recently with readers’ comments disappearing. I’m
    sorry this happened to you.
    Thank you for your comment.
    I do think that NP programs need standards and oversight–just like MD programs.
    As you know, because Louisiana’s medical infrastructure was devastated by Katrina, (and insufficientt federal help) the medical system there is in disarray
    I hope (but don’t know with any certainty) that the NP program in other states is in better shape.

  20. Maggie,
    Thanks for your reply. My original post was not deleted – this was my mistake. It “disappeared” when I refreshed my screen. I think it moved from the bottom to the top of the comments (or something like that). In any event please accept my apologies for that – and my failure to spell check :).
    I hope that you and Laurel are closer to the truth than I am with respect to the potential of the NP program, but I remain sceptical based on my personal experience. And am saddened to say that I side with those physicians who say if you want to practice medicine – go to med school. It’s not fair to dismiss this as a turf battle. We all know nurses who are outstanding – either on a interpersonal level or a clinical level or both. But they are the cream of the crop. And notwithstanding these fine individuals, the profession as a whole has been over glorified. If you or a loved one are ever admitted to hospital, maintain a healthy scepticism about your physician’s competence, and double down on this with respect to your nurses.
    The NPs and PAs that I work with every day need supervision. Just as the Nurse Anesthetists do in the OR. Some more than others, to be sure. How much supervision they need can be determined by the physician that supervises them, and we should expect to see a tendency towards more autonomy as they gain experience. And while some individual NPs are equally or even more capable than some individual MDs, as a group, and especially out of the gate, they are not “on par”. Not even close.
    Jackytar

  21. Jackytar, Thanks for your comments. I’m a family doc who has worked with and supervised NPs for years. One is sitting in her office just across the hall as I type this. She is good, with 30 years of experience, and she can do most of what I do, but I am much better at two main things: Managing complex problems, both acute and chronic, and making esoteric diagnoses. I am also much faster and see about one more pt per hour, definitely a consideration in these PC shortage days.
    I recently diagnosed a pt with Waldenstrom’s macroglobulinemia. In 30 years, she had never heard of it. She saw a pt recently and presented the pt to me. I immediately suspected bronchiectasis, which we then diagnosed with a chest CT. She was only vaguely familiar with the term.
    Does such diagnosis show up in overall quality of care statistics? Probably not. Both pts would have gotten worse and then would have been sent to a subspecialist who would have made the diagnosis. But it’s real medicine, something that will be lost if doctors leave primary care.

  22. Wisewon, Dr. Matlev,J. Rossi, Jackytar, Laurel, DLucky, Susan
    Wisewon–
    Good to hear from you. I agree– in making my point I over-emphasized “comfort and care.”
    As you know, I believe that evidence-based medicine is essential, and that means robust scientific data is needed. Providers need to understand that data.
    But today’s Ph.D. programs for NPs do seem to empahsize the science. (I’m particuarly impressed by what I have read about Johns Hopkins program that focuses on comparative effectiveness.)
    And nurses in these programs are studying for as many years as med students. They don’t do a residency per se, but when they graduate almost all work with M.D. s at least for the first few years. They are supervised, much like residents.
    This seems to me essential for any health care provider.
    I also agree that medical education needs to be re-designed– with more emphasis on comfort, care, acknowledging the ambiguities of medicine (see Gawande),learning how to explain risks, benefits and odds to patients, etc.
    I also think that primary care should be be a separate track–and I suspect that, in general, not all specialties should require the same courses and rotations. It strikes me that oncologists probably need a course in palliative care And a course in pain managements. Other specialists might well need one or the other, but not both.
    Finally, my guess is that NP programs need re-design and upgrading to match the best programs. The field is moving quickly, and probably not all programs are preparing NPs for the new responsibilities that they will be taking on.
    Dr. Matlev–
    IF you read my book, you would realize that I point to Kaiser Permanente in N. California as what Dartmouth’s Jack Wennberg calls “the gold standard” for mainstream healthcare care in the U.S. .
    In Money-Driven Medicine I follow Paul Starr in defining “corporate health care” as “for-profit health care.”
    Unfortunately, some solo practitioners see themselves as entrepreneurs running a business. Like a large coporation, they judge their success based on revenues and profits. They are just as “corporate” as a for-profit hospital or drug company.
    “Corporate medicine” is not about size; it is about values and priorities. See the last pages of Starr’s book: The Transformation of American Medicine” where he defines hte “corporatization of medicine” (I quote him in my book.)
    On small practices: For decades, we have been running U.S. health care as a cottage industry with zillions of small practices. This is terribly expensive (overhead that enjoys no economies of scale) and dangerous (no one is looking over the shoulder of these solo practitioners and very small groups.
    A doctor may be 30 years behind the times; he may be an alcoholic; he may be lazy; he may be affable, but simply not very bright. (Old joke: what do we call the student who graduated last in his med school class?
    ‘Doctor’”
    He may be sloppy.
    I once went to a well known ENT specialist in Manhattan with a large following who was smoking a cigar while examining my ears– dripped ash on me. Last time I saw him. Who knows why he has a large following. Perhaps he once was very good.)
    If a subpar doctor is working in a large group like Kaiser or the Cleveland Clinic, he will be spotted. All docs are looking at the same chart, and someone will say “Hey, Bill– I’m wondering . . why did you prescribe X for Mrs. Smith . . ”
    Kaiser does, occasionally, fire docs. Or it decides that they can no longer do certain tasks–reading mammograms, for instance, because they just aren’t good enough.
    As Dr, Atul Gawande points out, doctors, like everyone else, live on a Bell Curve. The 10% to the far right are excellent.
    The 10% to the far left are not very good. The vast majority, in the middle are, as he says “mediocre.”
    This is why the majority of docs need to be in large groups where they can consult with each other, get advice . . These days no one doctor (or three doctors) knows everything that a doctor needs to know, even in his own specialty.
    Of course a wise solo practitioner will consult with other doctors. But it isn’t always easy– you wind up playing phone tag.
    When doctors are all working together for Kaiser, Mayo, Geisinger, Intermountain, Cleveland Clnic, specialists and primary care docs can collaborate easily.
    I am in no way denigrating the value of primary care. I agree that in countries where patients get more primary care (and in regions of the U.S. where patients get more primary care) outcomes are better.
    But we also know that, by and large, outcomes are better when doctors are working in large multi-specialty groups (which include primary care docs. I think of “primary care,” “family practice,” etc. as a “specialty.” )
    Collaboration is key. Medicine is a team sport.
    And the docs on the right -hand end of the curve need to be watching out for the docs on the left end.
    P.S.– when my husband and I went to the hand surgeon for a follow-up appt., I didn’t see the younger doc. I asked about him. He was no longer part of the hand surgeon’s practice.
    The older hand surgeon himself works as part of a multi-specialty group at a large hospital down the block from his smaller private practice.
    J. Rossi–
    I can’t help but wonder–have you ever asked your NP what she feels she is better at than you?
    If she has been doing this for 30 years, and you think that she is generally good, chances are she is excellent in some areas. . . (Getting women patients to open up and give a candid medical history? Giving older patients more time?)
    I’m not sure that the fact that you are “faster” is necessarily a plus. Of course we need efficient medical care, but these days, most patients perceive primary care providers as too fast. Particularly because PCPs see many older patients–who typically suffer from more than one ailment, and may be a little slower in explaining their problems — your NP might be giving some of those patients better care.
    I’m sure you are better at diagnosing more esoteric diseases. Though as you point out, as long as a PCP or NP refers cases that they cannot diagnose to a specialist, the patient will be well served.
    Finally, your NP has been practicing for 30 years.
    My impression is that training for NPs has sdvanced significantly in the past 30 years.
    If you hired someone who had completed a program 4 years ago, you might be surprised by what he (or she) could do.
    Jackytar–
    It seems that NP training is becoming more rigorous.
    So I would think that, going foward, NPs will need less supervision.
    Also people do what their parents, teachers, bosses, think they can do. If NPs are working in a culture which assumes that they need supervision, they will be more passive, and rely on docs as a crutch to tell them what to do.
    My basic feeling is that the NP profession has been changing rapidly over the past 10 years, and will change even more over the next 10 years.
    Laurel– I believe that you work in a very good NP program–where students can fail.
    My guess is that there may be NP programs out there that are not as good, and need to be strengthened . We pay a lot of attention to med schools, but just as we have given NPs short shrift, we probably have given NP programs short shrift, thinking it just isn’t nearly as important.. (This is just a guess– I don’t know that much about NP education).
    But going forward, I suspect that this will change. And programs like yours will serve as models.
    Dlucky–
    Thank you. And I agree,
    it’s the guild that is strongly opposed to NPs.
    Many docs appreciate NPs (as this thread shows.)
    Some are sketpical about NPs practicing independently. And I, too think that after graduating NPs should work with docs for a few years (much as med students go into residency.)
    But after that, I’m persuaded that NPs can practice independently. Just like doctors, there will be times when they need to consult with an M.D. (For instance if a delivery suddenly becomes very complicated, a nurse midwife will call for a OB/Gyn (or perhaps another NP) in the hospital.
    Susan–
    Thanks much for acknowledging, that medicine would still attract very talented individuals if pathologists were paid $250,000.
    If people are willing to pay people in your group $500,000, I certainly wouldn’t expect you to say: “Oh no, this is too much” and give it back to the insurers.
    Again, many thanks for your candor.

  23. i’m sorry but it is a complete fantasy to think that NPs working with docs for a few years is the same as going to residency.
    the NPs are not getting anything near the supervision residents get, nor are they attending didactics or sitting through M&M conferences or grand rounds with the same frequency and intensity as in residency.
    doctors need to be paid to supervise the NPs and be given time to do appropriate training in the model you propose.
    yes they can send patients to specialists when they don’t know what to do. i don’t know whether that equates to saving the system money however.
    i think a big first step from the NP profession would be to establish national boards for their practices to demonstrate the competencies they state their graduates and practitioners have. these should be specialty specific to ensure that they can provide care. then there could be some justification to their claim that they should be eligible to practice on the same footing. the oversight should be through established state licensing boards-same as for doctors and dentists and podiatrists and pa’s.

  24. anonymous–
    There are already certification boards for nurse practitioner midwives, pediatric nurse
    practioners, family nurse practitioners, etc. etc. etc.
    With regard to residency for primary care,
    Chrstine Cassels, president of the American Board of Internal Medicine has told me that at too many academic medical centers, primary care residents are “working in a basement, seeing uninsured and Medicaid patients, with almost no resources.”
    In more than one hospital in NYC, residents work with “very little supervision.”
    The fact that residents work long hours is seen as a threat to patient safety (by the IOM) and undermines the learning experience.
    I am sure the amount of supervision NPs receive when working in large city hospitals also varies.
    Finaly health care reformers in medical education are increasingly interested in training medical students and nurse practioners together–so that they can learn to collaborate.
    I would suggest that residency programs for primary care and training of NPs after they graduate both need to be improved, with an eye toward training them in collaborative, evidence-based patient-centered medicine.

  25. Maggie, Thanks for making my point for me, namely that doctors and NPs are different and better at different things. Which is why, in a better system, we should work together.
    What is my NP better at? Making the worried well feel comfortable, doing routine stuff, doing routine GYN stuff. What am I better at? Diagnosis and treatment of serious medical problems, such as acute severe disease (MI, pulmonary embolism, acute abdominal pain, and yes, acute severe pelvic pain in a female) or severe or complex chronic disease. Which is why we work together, as we should.
    Newly minted NPs are quite dangerous and require close supervision, like brand-new interns. They get better after a few years. My experienced NP is much safer.
    Re: older pts, again, it depends on how sick or complicated the pt is, but my NP generally gives excellent care.
    But all these are side issues. The main issue is whether, given the current NP juggernaut, docs will leave primary care en masse. You seem not to be worried by the prospect. My 21 years as a frontline doc makes me less sanguine about a PC system without MDs. Note that I am not blaming the NPs, most of whom do excellent work and without whom we would be in worse shape than we’re already in. This is a societal issue. Perhaps docs will morph into PC consultants. Interesting times.

  26. I like my good friend and family doctor’s take on this. In the end, America will choose soley on cost. Most will eat at McDonalds for the 99 cent burger instead of the $7.99 charged at a good restaurant. Why is Wal-Mart the biggest company in the history of mankind? Cheap sells!
    It’s not saying that all NP’s deliver poor care, they do not, but they do provide cheap care. Not all doctors provide “better” care. There are many doctors that one would not send a mangey dog to. But looking at the forest instead of the trees, doctors indeed do go to med school and residency and NP’s do not.
    He spent $250,000 and 11 years of his life to become a doctor. NP’s spend less time and less money. If this happens, he can foresee all people who go to med school going into specialty medicine. Why go through all that when one could do the same thing in less time for less money?

  27. jrossi & Greg
    Jrossi– I agree that NPS and docs are different and can well imagine, given difference in training, that they are better at different things.
    And I agree that they should work collaboratively.
    That, however, doesn’t mean that an M.D. should “supervise” an NP.
    They should consult with each other, draw on each others strenghts.
    I also believe strongly that so much of what an M.D. or a NP knows is learned experientially–through years of seeing patients.
    A great many docs say that a good part (10%? 25%? of what they studied in med school has little or no relevance to their practice of medicine.)
    This leads me to believe that an NP with 20 years experience might well run a community clnic where she supervised residents as well as young doctors, while collaborating with the older docs who worked in the clinic.
    Finally, virtually everyone involved in medical education seems to believe that it needs to be re-vamped.
    I suspect that primary care education for M.D.s is in particlar need of change. Since academic medical centers tend to look down on primary care, working conditions for residents are often terrible.
    I think if we change the working conditions,subsidize med school for those who choose primary care, and make an effort to admit med students from low-income and rural backgrounds who are likely to go into primary care we coudl actually increase the number of docs who choose primary care.
    (Interestingly, older students– who graduate from med school when they’re over 30 and Mexican Americans are also much more likely to choose primary care and to be willing to work in underserved areas.
    African-Americans coming from low-income families also are more likely to choose primary care.
    See also my reply to Greg below.
    Greg: Many doctors who go into family practice or primary care because that is what they wnat to do with their lives.
    They have little interest in spending their lives focused on one body part.
    They like the idea of a continuous relationship with patients adn their famlies that lasts for years.
    To say that all docs would go into specialties if NPs
    also could practice medicine after spending less time and money on their training suggests that these decisions are all about time and money–that there is no such thing as a vocation.
    A great many law students decide to go into less lucrative areas of legal practice–even though they spent as much time and money in school as those who wind up in the highest paid positions in corporate law.
    Many lawyers would find those jobs boring, just as many docs would finding doing colonoscopies, day in, day out, boring.
    Finally, when it comes to heatlhcare, “Cheap” does not sell. We spend 80% of oru healthcare dolalrs when we are very sick, suffering from a chronic disease over many years.
    People who are very sick are not looking for a bargain. Tell them that this doctor charges 20% less and they’ll run in the opposite direction, afraid that he’s not as good,and therefore can’t attract patients. (Young and inexperienced? Older and somewhat forgetful?
    A drinking problem? No one wants to find out.)

  28. Greg, You are exactly right. It makes no sense to spend all that time and money if you could become an NP and do the same job, for the same money and the same respect. For some reason the host of this blog can’t seem to understand this, or perhaps, she is unwilling to understand it for ideological reasons. I strongly suspect docs will continue to flee primary care, and I, unlike our host, precept medical students (at the University of Washington, the number 1 primary care med school in the country) who tell me frankly that primary care is not on their radar screen.
    And the idea that there is a large crop of rural, older people who are going to get into med school and solve this crisis is simply a pipedream. Simply ridiculous.

  29. jrossi–
    I’m sorry that you don’t seem realize that many docs chose primary care simply because it’s what they want to do.
    It’s a vocation.
    What it costs someone else to become a primary care provider, really don’t factor into the equation.

  30. I went to a seminar yesterday at M.D. Anderson hospital.
    One person commented that NPs could very well replace MDs at less cost, but what do we do about the specialists?
    Primary care doctors aren’t able to do the same work at less cost.
    Then, the speaker noted that over the next 20 years, we will have 30% fewer specialists to satisfy the demand.
    I wondered “Doesn’t supply and demand also mean that the people demanding services are able to pay for them?”
    Don Levit

  31. Don–
    NPs are already in the specialities– we have board certified nurse anesthesiologists, board certified pediatric nurses,
    nurse practitioners who work with orthopedists (one patient who had her knee “re-done” said she say the orthopod only briefly–the NP did most of the work.)
    Health Care is in a bubble–not unlike a Wall Street bubble. Specialists on the top half of the income ladder are way, way, overpaid–much like real estate in many parts fo the country.
    In coming years, the bubble will burst. NPs will replace some docs, but docs will still go into the specialties, but they’ll go to med school with much more realistic expectations about future income. We’ll also probably subsidize more and more med school education (as other countires do) so they won’t emerge from school with huge loans.
    Finally, docs as well as NPs will do primary care, and primary care docs will be better-paid than they are today (and as they are in other countries. In the UK, primary care docs make more than many specialists.)
    One area that I think will change is child-birth. In the US 10% of babies are delivered by nurse mid-wives. In Europe they do 70% of the deliveries–and outcomes are better.
    U.S. docs do way too many C-sections–dangerous for baby and mother. They also induce labor too often–which then makes a C-sections more likely.
    Patient satisfaction tends to be higher with midwives. . .
    Finally, teh laws of supply and demand don’t work in health care markets. The first health care economist– Kenneth Arrow– figured this out many years ago.

  32. Maggie,
    I don’t know how to say this, but I read this twice and the message makes me uncomfortable.
    We have a problem, I agree. We have a shortage of primary care docs and we are overpaying specialists. I also agree that NPs and PAs, if utilized more efficiently can alleviate some of the problem.
    However, I cannot agree that the ultimate solution is to train physicians to be more like nurses. Traditionally, it was the doctor’s job to fight and solve problems and the nurse’s job to aid and comfort the patient. That does not mean that doctors are trained to be callous. Quite the opposite. The importance of listening and taking good histories and treating the whole person has always been part of medical training (see William Osler’s writings).
    However, doctors need to also be scientists, and all that course work that seems unnecessary, really isn’t. There is rigor and discipline that needs to be learned and part of it is to learn how to memorize and how to commit hundreds of seemingly unimportant details to memory. It’s an exercise in learning how to learn. There will be no computers to look stuff up on when you are up to your elbows in someone’s chest cavity.
    And there is value to learning how to act under duress too. It’s not a theoretical thing. It has to be experienced, as any one who served in the military can tell you. Medicine is sometimes very similar to battle too. You are fighting an enemy and you have to want to win, and you have to have the physical and mental abilities to do what it takes to win. If palliative care would have been the objective all along, we would still have people dying from the plague, albeit in great comfort.
    I really think we need to restore primary care to what it was a few decades ago and what it is in other more effective countries. Primary care docs should go back to practicing medicine instead of triaging referrals to overpaid specialists. It is very possible that the reason we have so few young doctors choosing primary care is not primarily financial, but the perception that primary care is not “real” medicine anymore. We have to fix that through reimbursement reform, or no matter how many NPs we throw at the problem, we will end up with the same price tag for an inferior product.

  33. To Sharon MD: Yes! Struggling through an expensive, frustrating medical education system only to do the same job as a nurse practitioner… and now nurses who want to call themselves “doctor.” There’s no question that it’s ego-deflating. Thank you for recognizing this and being honest.
    To Keith Sarpolis: there is tremendous productivity pressure on NPs, and taking call has been part of most places I’ve worked. I see a patient every 20 minutes, regardless of the complaint. It’s a tough, tight schedule. We’re in business too, and I have to make sure I see enough volume and code correctly to make a profit.
    Doc D: that’s just it! There is wide variation among NPs, just as there is among physicians. Some need tight supervision, others are quite independent. I tend to collaborate a lot, but it’s more due to academic geekiness than medical necessity.
    Nurse practitioners were designed to be self-regulating. A lot of this has to do with the specific person and practice environment. More acute or complex patient settings warrant closer supervision and collaboration–just as they do among physicians. It’s too hard to make a blanket statement about NPs and supervision as a whole.
    Maggie: about malpractice and ordering tests. There have been mixed reports on this. Some claim we order too many tests, others not enough. Some say we over-refer, others not enough. Nothing consistent. I’ve been told that “NPs don’t order enough tests because they don’t know what the tests are or mean.” (I always find that offensive.)
    One thing that NPs have drilled into their heads is cost effectiveness. We’re taught (and I taught my students) to be judicious about costs. Don’t “shotgun,” be wary of over-ordering CT scans, etc. Medical schools and residency programs have been slower to integrate finance and cost issues in to their curricula.
    Physician critics often point out that NPs are unaware of unusual pathologies, or anything other than a sore throat. I invite those physicians to review our textbooks and curricula. When I taught, and as a student, we had a mix of NPs, pharmacologists, physicians, physical therapists, physiologists, and podiatrists teaching us.
    Earlier in the week, a 30-something guy came in with a cold. I just happened to notice an irregular skin lesion during his visit. I immediately grabbed a scalpel and some lidocaine and performed a shave biopsy on the spot (screw the cold; he can have some Sudafed later.) It was a melanoma, caught just in time. My neighbors–savvy politicians–said that the angry blogger’s response would be, “You got lucky.” That was definitely NOT luck.

  34. DNP’s are a joke. You could get the degree online! Can you imagine the uproar if you can get a medical degree online. But yet no one has a problem with DNPs calling themselves doctors and prescribing medication to patients. Now NP’s are going into specialties like derm and cardiology. I can just see 20 years from now an NP neurosurgery program called Certified Nurse Neurosurgery Specialist. NP’s are pathetic, they’re a bunch of people who couldn’t get in or hack it in med school who want to go around “playing doctor”!

  35. Actually, Bill, one can only get a master’s or doctorate DEGREE online. One canNOT get the clinicals online, nor the certification for license to practice. Clinical hours must still be accomplished the traditional fashion, and most importantly the certification to practice is accompanied by a national exam. It is the same exam that all candidates (whether online or at brick-and-mortar schools) must pass. So regardless of whether the course offerings are online or not is irrelevant. What matters is the maturity and capability of the student to procure the knowledge and learning available at whatever resource (web or physical) in order to pass the exact same real world certification exam. Degrees are degrees. Just some letters behind a name. What matters is the license. And the manner of obtaining that has not changed one iota. Your post seems to be terribly misinformed and just plain old…angry.

  36. Margalit–Thanks for your very thoughtful and candid comment.
    You write: “The importance of listening and taking good histories and treating the whole person has always been part of medical training (see William Osler’s writings).. .
    I agree– this is part of the tradition. And Osler’s writings are great.
    But today, I hear more and more medical students and medical educators who are not happy with the sysem saying that med students are not being taught to take a history, listen to patients and lay hands on to make a diagnosis. Too many are simply learning how to order tests.
    At the same time, I agree that in my post I over-emphasized how nurses focus on comfort & care.
    Of course, cure is a top priority. But too often, patients are tortured as docs focus on cure. More importantly, the docs don’t ask a very sick patient “What do you want?”
    Not all patients want to fight to the bitter end. Not all patients see Death as the enemy . Not all patients want to be part of a “military” action aimed at defeating death. If the patient survives and goes to a nursing home for 4 or 5 years before he dies, this could make the doc feel better, but it won’t necessarily make the patient feel better.
    Meanwhile, many docs say that they don’t necessarily need many of the science courses that they take in med school.
    Increasingly, med school educators and med students seem to be saying that some of these
    courses are unnecessary.
    See my post here http://www.healthbeatblog.com/2009/05/reinventing-the-way-we-train-doctors-and-nurses-.html on a Mayo Clinic conference on med school education.
    I begins: “While in medical school, students are supposed to know the answers. They spend hours cramming, memorizing arcane language and hard-to-remember numbers so that if the question appears on a test—or worse still, if a resident decides to quiz them during rounds—they can answer it.
    “I don’t know, but I know where to look it up,” is not an acceptable response.
    “Looking up the answer is considered cheating,” Dr. Denis Cortese, president and CEO of the Mayo Clinic pointed out on the opening day of Mayo’ s National Symposium on Medical and Health Care Education Reform.
    “Yet, Cortese observed, once the student becomes a doctor, he is supposed to ‘chea’”—i.e. look things up. He is not supposed to ‘take a stab’ at the right dosage the way he might take a stab at the right answer on an exam. His patient’s well-being depends upon him knowing where and how to look up the information he needs, or whom to consult. A doctor who is reluctant to admit ‘I don’t know’ is a dangerous doctor.”

  37. This is funny/scary. Matt NP did a shave biopsy on a melanoma pt. He does not seem to realize that full thickness biopsies are indicated for melanoma, not shave biopsies. Example 1 on why NPs need physician supervision. They don’t know enough.

  38. For an irregular or suspicious nevus, a shave biopsy is perfectly acceptable. I brought him back for an excisional biopsy once I saw the path report.

  39. The real problem is the over-emphasis on treatment at the expense of making a correct diagnosis. A patient can “make the rounds” of all the specialists, each of whom can do every test in their armamentarium, without ever obtaining a correct diagnosis, and therefore effective treatment. More here. (will appear 4/29)

  40. Acutally Matt an “excisional biopsy” is NOT standard of care for melanoma, rather a wide excision with 1 or 2 cm margins depending on depth.

  41. Matr Freeman, NPs management of his melanoma patient was completely incorrect, and dangerous. A shave biopsy is never indicated when there is a suspicion of melanoma- it makes it impossible for the pathologist to adequately evaluate the depth of the melanoma, which is critical for staging. His “treatment” by exicisional biopsy is incorrect. The proper treatment is a wide local exicion down to the deep fascia.
    I hope, for his patient’s sake, that Matt has sent him to someone that will give him the proper care.
    This has been my experience with many (not all!) NPs- they don’t know when they are out of their league. Matt is out of his league, and his unwillingness to admit that is a problem.

  42. This case illustrates the issue. This isn’t gastritis. It’s melanoma. A shave biopsy and thereafter excisional biopsy can leave the pathologist guessing as to the depth which can affect adjuvant treatment and wide local exision. Now Matt may feel that “It was a melanoma, caught just in time.” but in reality he made life harder for those of us who actually treat melanoma. He should have referred out. Am I making sense here maggie? Is it getting through? You can name drop all you like about various “experts” you have interviewed and hence makes you believe you really know the subject, but unless you have actually spent time in our shoes, well then you are in reality little more than a self-appointed health policy wonk who overall just adds more chaff to an overabundance of clutter. I firmly feel there is a real role for NP’s but it is not what your agenda has determined.

  43. As a pathologist, the NP who did the shave on the melanoma and then excision is completely wrong and has in fact comprised the diagnosis for this patient. Pay attention Maggie. We aren’t playing with dolls here.

  44. On Melanoma- Everyone–
    I am not an oncologist or a dermatologist.
    But a month ago I went to a dermatologist who specializes in cancer. I had gone to her because I was concerned about something that turned out to be nothing
    Then I mentioned a little red red spot on my arm that has been there for a 4 or 5 years. She sliced a bit from from top of it (I assume this is what you mean by a “shave”.)
    She then sent this specimen to a lab.
    Perhaps what she did wasn’t professional. But she is an M.D. practicing on Park Avenue in Manhttan.
    A doctor who is a friend recommended her.
    Her location doesn’t mean that she is right, but I have a hard time thinking that she simply has no idea what she is doing.
    Perhaps there is a diagreement among M.D.s on this point?

  45. Maggie! You are so not getting it!!
    Shave biopsies are fine WHEN MELANOMA IS NOT SUSPECTED; ie, a little red spot that’s been there for years. Matt the nurse would have been just as right to shave that as was your Park Avenue dermatologist.
    Matt the nurse was also apparently correct to suspect melanoma in the lesion he saw, but he was NOT correct in his choice of biopsy technique. That’s what we mean by NPs not recognizing their limitations.
    Please tell me you’re not being deliberately obtuse. I thought so much better of you than that.

  46. Dinosaur #1 and Everyone–
    First, my dermatologist said she was taking a very thin slice of this red spot because she was concenned about melanoma—emphasizing that this was a very slight possibility.
    That’s all I know. I’m not a dermatologist or an oncologist.
    I also don’t know what the “lesion” Matt saw looked like. Some of you seem to be assuming that it was much thicker and larger than my little red spot.
    You may well be right. None of us have seen it.
    But,one question: if what Matt did caused a problem for the dermatologist who
    utlimately took over the case and confirmed the diagnosis, wouldn’t he have said something to Matt?
    Matt is a pretty smart guy. In his initial e-mail to me he noted that he has 11 years of post-secondary education– including a degree from Yale and a DNP (Docotorate Nurse practionier) from Duke. He also has taught Nurse practioners.
    So I wouldn’t think he would boast about something if he had made a mistake (and I would assume that an M.D. would have pointed out the mistake.)
    But I don’t know. Perhaps he was wrong.
    The more important point it that the usefulness of NPs does not turn on this one anecdote.
    This has been a lively thread. To me it suggests that NP can be very useful, but that we want to take a close look at training and credentialing to make sure that the standards are high.
    There are instances when NPs seem to work solo successfully (midwives delivering babies in hospitals where there are M.D.s on the premises in an emergency–but they don’t need direct supervisoin.)
    And there are cases where NPs work solo because they are the only medical professional around– places in some of the poorest parts of the rural South. We could use more primary care docs in these areas, but few want ot work there.
    Finally, we also want to look at residencies for M.D.s–some programs aren’t as good as they should be —particularly in primary care.
    And when possible or practical it would be great if NPs in training and residents could learn to work together as part of their education.

  47. Dinosaur–
    I just spent quite a bit of time putting a comment up on your webiste.
    When I submitted it, it simply disappeared.
    Luckily, I kept a copy of it, here it is:
    Dinosaur-
    You’re probably not a regular reader of my blog ( HealthBeat ) and so would have no reason to know my views on primary care.
    In the one post your read, I couldn’t include (or repeat) everything I have to say about something as complicated as what primary care is or what it should be.
    Let me just say that, in the past, I have written posts about primary care and diagnosis– and basically agree with everything that you and Peggy are saying.
    A couple of years ago I gave a talk at a Mayo Clinic conference that focused on reforming medical educatoin.
    At the conferenece one medical student stood up and complained that med students are not being taught to diagnose–they are being taught to order a battery of tests and count on the tests to do the diagnosis.
    Others agreed.
    There seemed to be a consensus among many in the room that students need to learn to diagnose the old-fashioend way– listening to the patient, observing the patient, feeling the knee (or whatever) asking the patient questions, listening carefully–and then ordering a test (or tests) if needed to confirm the diagnosis.
    As Peggy says, docs need to be paid for the time to do all of that. It’s hard to pay them when paying fee-for service–though I supposed you could pay them like lawyers, for every 15 minutes. But that means more paperwork. This is why I like the experiments that Medicare is trying–finding new ways to pay for value, not volume, so that docs are paid for all of the time they spent–not just for the visit.
    But even if they are paid for the time it takes to diagnose, docs need to be trained to do this–in med school, in residenecy. A hospitalist I know who teaches residents at a NYC hopsital with a very good reputation says that they tend to just order a batch of tests–without thinking. He’s trying to get them to think, but he says they have been taught to be “thorough.” (Which means more tests–they are not very good at taking histories.)
    This is a major reason why so many of today’s PCPs simply refer patients to specialists. (This certainly is the norm in Manhattan. It’s the medical culture here–what many doctors do and what many patients expect.) I’m not in favor of this–it’s a very wasteful way to practice medicine. Research shows that outcomes are as good if not better in parts of the countyr where patients see primary care docs more often and specialists less often. I’ve written about this at length.
    Finally, I am not talking about NPs “replacing” physicians except insofar as physicians don’t want to do a job–or won’t do it unless society will pay them more than taxpayers can afford. (Gov’t now pays half of medical bills and its share is growing. So ultimately, we’re talking about taxpayers footing the bill.)
    If an NP is willing to deliver very good primary care for $150,000 a year net income, should we pay an M.D. $250,000 a year to deliver primary care? I don’t think we can afford it. At the same time, when the primary care doc looks around and compares himself to friends he knows from med school who are now dermatologists earning $350,00 a year, he may well feel underpaid. (Money is relative.)
    If he’s happy being a primary care doc earning $175,000 (current median income, with half of all PCPs earning more and half earning less) that’s fine. But many of the half earning less are very unhappy and wish they weren’t PCPs.
    Meanwhile, primary care NPs earn an average of $80,000-$95,000. Since money is relative, this suggests that many would be happy doing the job for less than $175,000. $125,000? $150,000? Maybe mid-career they too should be paid $175,000. I don’t knowl
    What I know for certain is that many of the PCP readers I hear from compare their pay to specialists’ pay. Sometimes they throw out numbers, saying it’s impossible to live well and raise a family on less than $300,000. Or they compare their pay to CEO pay. The problem is that at the top of the U.S. income ladder salaries are so out of whack that many individuals have come to have a very skewed vision of what is “enough.”
    But I’ve been talking about cost. What about quality of care? All of the studies suggest that many NPs provide excellent care. If we take a close look at NP training and credientialling—-and weed out the sub-par NPs– would we be better off having NPs who like the job doing it for $125,00 or having PCPs who are very unhappy doing it for $160,000? I would sumbit that low job satisfaction undermines the quality of care. (And note, today more and more NPs are PH.Ds who spend many more years in training that the RNs of the past. Wcience coureses are rigorous. )
    Should some very experienced NPs work without a doctor on the premises? Maybe. Especially if we can’t find MDs willing to do the job–even for $175,000. (MDs are very reluctant to work in certain places– rural Louisiana, for instance, and in some places the only medical professionals available are NPs. And these days, relatively few MDs chose to become gerontologists– they just don’t like treating older patients all day. Older patients are frustrating, I’m told, because so often, there is little you can do for them. The aches and pains of aging are, to some degree, inevitable.
    Finally, of course I haven’t suggested that “comfort” and “care” is more important than cure or treatment. But at the Mayo confernece the docs and nurses there seemed to agree that med schools need to focus more on comfort and care–i.e. required courses in palliative care and pain management; learning to hold a patients’ hand when there is nothing else you can do; accepting the fact that often, there will be nothing you can do. (AT least once, in practically every patient’s life.) Many doctors have written about how the rage to “cure” has caused doctors to over-treat dying patients because those docs have been taught that every death is a failure. (I’m thinking of doctor/authors like Don Berwick, Diane Meier . . .)
    Finally, the stunning success of nurse-midwives suggests that the emphais on “comfort and care” in their training can be extremely useful in some situations. When a nurse-midwife delivers there are many fewer C-sections and many fewer inductions (which often lead to C-sectoins) than when a doctor attends an average-risk or low-risk mother.
    Good medical reserach shows that we are doing way too many C-sections, endangering mothers and babies. In some parts of the country 40% of births are C-sections. For the first time in decades, maternal mortalities are rising, and reserachers say this is becuase of the unnecessary C-sections.
    The reserarch also shows that older women, younger women, poor women , rich women and women of all ethnic backgrounds are all having more C-sections. This is not a consumer-driven phenomena. Mothers report that doctors pressure them to have a C-section. C-sections are growing fastest among women under 25–they seem to respond more easily to pressure from the doctor.
    Meanwhile, when nurse midwives deliver, they are far more willing to let nature take its course, even if it means sitting through a 10 or 12 hour delivery, spending much of the time ‘comforting” and “caring” for mother and baby, while waiting it out.
    Ultimately, I agree most of all with the comment at the top of this thread (on the Dinosaur post) from LIttle D. .
    Maggie Mahar http://www.healthbeatblog.org

  48. Maggie there is no disagreement among MD’s on this subject.
    The NCCN clearly states that shave biopsies may compromise pathologic diagnosis and complete assessment of breslow thickness. Shave biopsy is acceptable when clinical suspicion is low (your “slight possibility” case). Look it up, it is on the web. Multiple doctor’s have pointed out this is inappropriate…PERIOD. I don’t care if Matt is a DNP and seems like a “smart guy”, it’s wrong.
    This is more than “one anecdote”. Shall I talk to you about the aggressive diffuse large B-cell lymphoma that was treated with multiple rounds of antibiotics by one NP? Or how about the multiple myeloma treated as DJD by another. Both cases actually came to me via astute ER docs who had an idea what they where looking at and consulted me after the initial “treatment” did not work. I can go on and on. NP’s have a role, but NP’s are not doctors with less pay. Everything is not gastritis dear maggie. In fact your quoted study should have had the corallary of a significant uncommon abdominal etiology that mimiced gastritis also.
    Lastly, I practice in rural america. I know exactly what the limitations are. I certainly am not a health care wonk who ponitificates from Manhattan. And in a nutshell that is the problem. All the healthcare experts and wonks who are making todays healthcare decisions really don’t understand the subject. They don’t actually work in the trenches. Frankly nobody even seems to care what the Doctor’s think. To you we are part of the problem. That is the problem. Sorry Maggie but your understanding of day to day medicine is only slightly better than my understanding of getting a PhD in english.

  49. Joe–
    As I said from the beginnining, I am Not a M.D., and so didn’t know whether “shaving” was okay, definitely wrong, or controversial.
    It seems that it comes down to how great the risk of melanomia is.
    Here’s what the American Cancer Society said in March: “A shave biopsy is useful in diagnosing many types of skin diseases and in sampling moles when the risk of melanoma is very low. But it is not generally recommended if a melanoma is suspected because a shave biopsy sample may not be thick enough to measure how deeply the melanoma has invaded the skin. ”
    So shave biopsy is not generally recommended unless the risk of melanomia is very low.
    Fine– I assume you judge risk by looking at the lesion while also considering the patient history and family history. Since you weren’t there to look at it, and since you didn’t talk to the patient, I’m not quite certain how you can be so sure that what Matt saw wasn’t “low risk.” But let’s assume it wasn’t and that he made a mistake in assessing risk.
    You also cite other instances when a NP mis-diagnosed– and I believe you.
    But haven’t you ever seen a patient who was mis-diagnosed by another M.D.?
    My ex-husband was diagnosed with cancer by two doctors. He didn’t have cancer. He had another disease that required an operation. When they operated, he almost bled out. He has a separate condition that can lead to profuse bleeding–his blood doesn’t clot. Somehow, this didn’t come up when they took a medical history. The doctors were very apologetic. He nearly died. The fact that he’s a lawyer made everyone extremely nervous, but he’s not into suing people. He was more upset with the doctors who told him he had cancer.
    Mistakes happen. M.Ds mis-diagnose. Going to med school doesn’t make anyone infallible.
    No one is trying to say that “NPs are doctors with less pay.”
    But we have a shortage of primary care docs in this country, and doctors tell me that even if you raise the pay significantly, you’re not going to get enough M.D.s willing to practice primary care, particuarly in rural areas.
    We could train more physicians, but most of them will still flock to the same places–leaving some regions underserved.
    Docs also tell me that raising the pay won’t create enough gerentologists.
    In some situations, well-trained NPs can do the job–for example outcomes appear to be as good or better for average-risk women when nurse-midwives (who are less likely to do C-sections.) deliver their babies.
    You seem to feel that only a doctor “in the trenches” can understand medicine.
    But any single doctor in the trenches knows only his own experience. For instance, you have had some bad experiences with NPs. Other doctors on this thread report good experiences with NPs.
    You work in a rural area. Docs I know practicing in the Bronx are up against different problems.
    But these are only anecdotes.
    Medical research goes behond the anecdote to tell us what happens when tens of thousands of babies are delivered by OB/gyns and by nurse midwives.
    The M.D./health experts who I know have and do practice medicine. They are very interested in what doctors think. But ultimately, they believe that medicine should be “patient centered” not “doctor centered.”
    That means looking at medical evidence and trying to figure out what would be best for the patient.
    The health policy decisions that we need to make are very complicated: we need to weigh the public good as well as what’s best for the individual patient while at the same time recognizing that resources are finite. We can’t let healthcare inflation continue to outstrip wage growth or growth of GDP. If we make better use of NPs they can help us rein in inflation. Offering incentives that will encourage med students to become PCPs will also help. Today, many patients see a very expensive specialist when a PCP could make the diagnosis.
    Research also tells us that if we admit more students from low-income famlies to med schools they are more likely to pick primary care, and low-income students from rural areas are far more likely to choose to become family docs in those areas. So we probably should think about recruiting more low-income students, and lowering GPA and test score requirements slightly since the research shows that these students tend to have slightly lower scores, though when it comes to clinical work, they do just as well. (This idea comes from a doctor who has a great deal of experience educating med students.)
    What I’m trying to say is that thinking about health care policy means thinking not just about what a doctor learns in medical school or when practicing medicine, but economics, public health, social policy, medical ethics, and the importance , from a patient’s perspective –of “care” and “comfort” as well as “cure.” NPs have something to add to the discussion.

  50. I have been a nurse for over twenty years and am currently pursuing my degree for nurse practitioner. I believe that unqualified and uncaring individuals exist both among the physician group and nurse groups. The certification exam does not always weed out these individuals. I have worked with many physcians that would have seriously harmed a patient if they would have not taken a moment to investigate what I had to tell them about the patient, pathophysicology, and pharmacology. I do not believe we can judge the entire profession upon the ones that are bad. What we need is some method of monitoring outcomes and dealing with those that are not providing quality – physicians and nurse practitioners. I have practiced with several physicians that have told me that my nursing judgement and knowledge is invaluable to them. I have also worked in units where it was imperative that I write orders and make medical decisions before I called the physician or the patient would have died. Nurses in critical care areas do this all of the time. As nurse practitioners, we are capable and providing us with the appropriate scope of practice affords us with the recognition and renumeration for our knowledge that we deserve. Regards to all.

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