A Doctor Confides, “My Primary Doc is a Nurse”

Last week I interviewed a doctor who told me that his primary care doc is a “physician assistant”  who has been trained to deliver primary care.   He said it casually, dropping the fact into a long conversation.

Dr. David Kauff is an internist at Seattle’s Group Health Cooperative (GHC), an organization that has a fabulous reputation–both among patients and among physicians—for its primary care program.  One reason is that at Group Health, doctors, physicians assistants and nurse practitioners work together in teams. “The success of our model is based on the fact that everyone in this together; we are corralled by a common purpose,” says Kauff, who also serves as GHC’s  Medical  Director for Practice and Leadership. 

I’ll be writing more about Group Health Cooperative in a few days.

 In this post, I would like to focus on the growing role of Nurse Practitioners (NPs) and Physician Assistants (PAs) as clinicians.  NPs are registered nurses who have gone on to earn a master’s or a doctorate. Some specialize in areas such as anesthesiology, pediatrics (pediatric nurses) or Ob-Gyn (certified nurse-midwives). NP’s can run clinics; some run their own practices.     

By contrast, physician assistants (PAs) don’t usually work alone. While physicians may not be on-site, typically doctors oversee their work.  

PAs are formally trained to provide diagnostic, therapeutic, and preventive health care services.  They take medical histories, examine and treat patients, order and interpret laboratory tests and X- rays, and make diagnoses. In many cases, they did not begin their careers as nurses. They may have been  paramedics, respiratory therapists, or emergency care technicians (EMTs) before becoming PAs.  

Currently, 17 states, plus the District of Columbia, let nurse practitioners operate independently.  In 33 states regulations vary. As this map  reveals, in some places NPs are not allowed to prescribe medication. In others, they may have to consult with a physician when treating patients.

It’s worth noting that NPs enjoy greater freedom in the Northwest, the Upper Middle West, and Northern New England (areas that some healthcare reformers refer to as “Canada South” because these states are in the vanguard of reform) as well as in the Southwest, where many NP’s started working in group practices, and they went out and established their own clinics. Nationwide, about 6,000 nurses operate independent primary-care practices.                                               

                                              Why Physicians Object

Today, 14 states are debating whether NPs should be allowed to practice on their own.  Many emphasize the difference in education and years of training. Though in truth, the length of training is not so different. Becoming a primary care doctor requires four years of medical school plus three years of residency. A nurse practitioner  attends nursing school for four years, then spends two to three years in graduate school, depending on whether he or she is getting an M.A. or a Ph.D. (In 2015, all nurse practitioners will be required to earn a Ph.D.) 

Most NPs also have nursing experience. At the University of Michigan, for instance, the average candidate admitted to the NP program has 7 years of hands-on experience as a nurse.  But while the number of years spent training are not so different, as I explain below, traditionally ,the nature of that training has been very different.   

Doctors say that they are worried about patient safety. “I see it as physicians being true to their oath ”  Dr. Adris Hoven, president-elect of the American Medical Association recently told Marketplace Health Care’s Dan Gorenstein.   Hoven insists that doctors are “not threatened” by NPs.  “At the end of the day what they want to do is deliver the best healthcare possible.”  

Dr. John Rowe, a professor of Health Policy and Management at Columbia’s School of Public Health, doesn’t buy the argument.  As he points out, nurse practitioners are already working without primary care doctors: “The fact is this is going on in 16-17 states,” he told Gorenstein, “and there is no evidence that it’s not good for the patient.”  A recent Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation backs him up: “studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar.”

At the same time, Rowe understands why doctors are uncomfortable. “The physicians feel they have something special to offer,” he explains. “And being told there are individuals who are less well trained can do it as well as they could is a very difficult lesson for them.”                                    

When I last wrote about nurse practitioners, back in 2010, one physician/reader (“Sharon M.D.”) was exceptionally candid on this point:

 “I think there’s enough work for all of us in primary care,” she wrote,” and I think NPs and PAs are vital to meeting the demand.”  But, she added: “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 through 4 years of medical school and 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. . . . and all that debt yet to be repaid!

Without question, she is right when she says that there is plenty of work for everyone. With millions of Americans joining our health care system in 2014 no one needs to worry about NPs pushing primary care physicians (PCPS) or family docs out of their jobs.

(Nor are nurses likely to bringing down reimbursements for primary care. To the contrary, the Affordable Care Act requires that insurers pay nurses working in their own clinics the same rates they pay doctors for the same services, starting next year.  Medicare  will continue to reimburse nurses at 85 percent of the doctors’ rate,  though the legislation boosts the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor’s

 Meanwhile, across the reform movement, there is a wide understanding that in the future, we must pay more for primary care — while reimbursing less for certain aggressive interventions that provide little or no benefit for certain patients.

More importantly, Sharon M.D. echoes a theme that I have heard repeated when physicians respond to the idea of NPs doing their work –and gaining the respect that they feel belongs to them:  “She didn’t go through what I went through: the ‘grueling’ years of training and residency.”

I can sympathize with doctors who say this.  Imagine what  it feels like then to be told that someone who went to nursing school, and then got a Ph.D. can do the same work you do—even though he or she doesn’t bear the scars of medical training that I describe in the post above. This is a sticky issue, made all the more difficult by the fact that medical school education and residency is so punitive.  (For a first person description of how medical students are abused, see Dr. Val Jones’ essay.)

Various studies have documented the bullying. One found that mistreated students frequently display symptoms of PTSD.  Another study, published in the Annals of Internal Medicine, showed “a high prevalence of suicidal ideation among US medical students and suggest that the increased risk for suicide among physicians may begin in medical school.”

(Let me be clear: I am not suggesting that nurses don’t bully each other; sometimes they bully young residents. But the problem seems to be greater in med school where it is part of the macho tradition of what was once a male profession.)  

Here, let me suggest that perhaps no one should be exposed to the psychological brutality and abuse that so many experience during medical training: the hazing that turns medical education into an endurance test, the bullying, the lack of  supportive mentoring, the intentional public humiliations. Meanwhile, the “See One, Do One, Teach One” philosophy can leave a student alone on the front lines of medicine, as a third-year medical student describes in the post above.

This tradition goes back to a time when “men were men” (and all med students were male).  Today few young men—and even fewer women—believe that this prepares them to be better physicians. The lashing only hardens them.  

As I suggest in “The Psychological Impact of Medical Training on Physicians” above, a good doctor needs fortitude, courage and compassion. Scar tissue is not required.

Going forward, if  we want U.S. healthcare to become a collaborative enterprise made up of caregivers who are not afraid to ask questions, admit mistakes, learn from each other—and even learn from their patients—we must change how we train physicians.

                               Communication and Collaboration                              

Reading the comments on the Marketplace HealthCare post, where Drs.  Hoven and Rowe disagree, I was impressed by one nurse-practitioner-in-training’s vision of a “better future” for healthcare :

“I am at an Ivy League institution and competed against hundreds of other outstanding candidates to come here, and my cohort is full of high caliber, intellectually strong individuals with a stunningly diverse array of life experiences to bring to their studies. I would put any of us up against any of the med students at this school in a battle of intellect and understanding. Our guest lecturers often come from the medical school, our anatomy class was taught by somebody from the med. school, and I would say that we are getting a superior education for what we are going to be doing.

“It is not a question of smart versus dumb, but a question of which philosophy of care you subscribe to. Nursing emphasizes treating the whole person, or whole family, and it emphasizes wellness, preventive care, and empowering individuals to take charge of their own health. My perception of doctors is that they are trained in recognizing and treating pathologies. My goal as an NP is to provide care for people such that they never develop the pathologies in the first place. If 1 in 7 healthcare dollars in this country is spent on treating chronic disease, then we need to address these issues BEFORE people get the Type II diabetes or CAD diagnosis. NPs can do that (come on, you know this next part is true), boring, less well-remunerated work that I do not see medical students signing up for in droves. Not many med students want to be Marcus Welby anymore.

“NP residencies are becoming increasingly common and available,” she adds.  “I am all for an extra time after school to work under supervision, especially if it is paid the way that residencies for doctors are paid.

“I would highly encourage … any doctors who are skeptical about the value of NPs to talk to us, find out what we can actually do, instead of just assuming that NPs are not adequately trained. Collaboration and dialogue will advance the healthcare of the citizens of the US much faster than engaging in turf wars and belittling.”

I would add that these days, more family doctors are, in fact, being trained to engage the whole person –or the whole family—and to help patients learn to manage their own chronic diseases. But she is right, many internists have been taught to focus on diagnosing pathologies.

And I absolutely agree with her last statement: The future of patient-centered healthcare in America is all about collaboration and dialogue, both between doctors and nurses, and between caregivers and patients.  We don’t have time for turf wars.  There is too much to be done.

            Being Part of a Team: Active Collaboration vs. Passive Cooperation

Both nurses and physicians have what Dr. Rowe calls “something special to offer.”  Their experience and training is not comparable, but precisely because it is different, a NP or PA can complement an M.D.’s skills.  Many doctors understand this, and believe that physicians, NPs and PAs should work together, in teams—as long as doctors call the shots.

For the American Medical Association, that last phrase is key. Although the AMA acknowledges that nurse practitioners can provide essential patient care, they believe that such care is most appropriately provided “as part of a physician-led team.”

The problem with the AMA’s position is that being part of a medical “team” is all about equality. Hierarchies dissolve.  Everyone feels free to speak up, to say, “Excuse me, but I think we slid over the third point on the check list.”

A recent report from the Robert Wood Johnson Foundation (RWJF)  quotes a NP talking about “the ‘moral distress’ a nurse may feel …seeing a surgeon rushing through, and skipping parts of, a safety checklist—and the ‘moral courage’ it can take to speak up. ‘A nurse who intervenes can make that surgeon very angry.’”  She needs support from the very top of the hospital’s administration, and all too often, that is not forthcoming—particularly if the surgeon is a rain-maker..

The RWJF paper cities the Institute of Medicine’s 2010 report, The Future of Nursing: Leading Change, Advancing Health. It recommends an expanded role for nurses in improving patient safety: “nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.” The report quotes Mary Jean Schumann, D.N.P, executive director of the Nursing Alliance for Quality Care (NAQC): “it comes down to the culture. Everyone needs to be heard. Too often,” she notes, “nurses are not in the room when solutions are devised and are brought in only when it’s time to talk about implementation.”

A study published in the American Journal of Critical Care suggests that some physicians just don’t understand that “collaboration” is all about “an interaction between doctor and nurse that ‘enable[s] the knowledge and skills of both professionals to synergistically influence the patient care being provided.’”

The paper describes a two-year project in an acute inpatient medical unit that divided patients into two wings. In one group a nurse practitioner was added to each inpatient medical team. The nurse practitioners accompanied the house staff in the morning on “work rounds” and attending physicians on teaching rounds

In the other wing, which served as the control group, there were staff nurses, but no NPs.  Over the two year-period, physicians, staff nurses and NPs all answered surveys designed to determine the degree of communication and collaboration in the two groups.

The surveys asked caregivers to answer questions on a scale of 1-100 with “1” meaning “never” and 100 meaning “always”

–Did nurses and doctors plan together before making decisions?

— Did nurses and doctors share in decision making?

— Did nurses and doctors cooperate in decisions?

— Was there open communication between doctors and nurses in making decisions?

— Did nurses and physicians receive complete, accurate and timely information from each other?

— Did they enjoy working together?

–Did staff nurses find it easy to ask the nurse practitioners and attending physicians questions?

Their answers were very different, depending on whether a physician, a nurse practitioner, or a staff nurse was answering the questions.

Physicians in the group that included NPs reported greater collaboration with nurses than did physicians in the control group where there were no NPs. By contrast, nurses and NPs in both groups reported similar levels of communication with physicians. In other words, the nurses saw little or no improvement.

But staff nurses did report better communication with NPs than with physicians when NPs were added to the mix.  Interestingly, physicians also reported improved communication and collaboration with other doctors in the groups where NPs worked with them.

In their summary the researchers (who were themselves physicians) observed: “the difference between physicians and nurses in their reports of a collaborative effort is striking.” The authors of the study tried to explain the difference, saying, “Physicians may define or view ‘collaboration’ in a different light than do nurses:

— “Perhaps the physicians thought that collaboration implied cooperation and follow-through with respect to following orders rather than mutual participation in decision making.”

— “Possibly, communication styles differ . . . so that physicians perceive collaboration whereas nurses feel they (ie, the nurses) are being ordered to do something.

— “Or, possibly the input the nurses gave was not valued or acted upon, and thus the interaction was not perceived by nurses as ‘collaboration.’”

Nevertheless, there was good news for patients:  In the group where NPs worked with physicians both  length of stay and cost for patients fell, without an increase in readmission rate and without reductions in health-related quality of life and satisfaction.”

                 Nurses Practitioners and Physician Assistants Are Here to Stay

Despite the controversy, in the next few years, NPs and PAs  will play a growing role in primary care. The simple fact is that we need them, and they are responding to the demand for their help.  NPs are now the fastest-growing group of primary care providers, with NP students who plan to enter primary care graduating at three times the rate of their medical student counterparts.

Could we entice more  med students to go into primary care by raising reimbursements? I don’t think the shortage of family docs is all about the money

Median income for primary care physicians is now approaching $200,000.  Half earn more; half earn less–sometimes much less. Many of those in the bottom half are underpaid; this is particularly true of young doctors who are struggling to pay off loans.  

But in the top half, those earning more than $200,000, (and sometimes significantly more), are well-compensated, especially if they work for a large institution that covers their overhead and malpractice insurance.

A first-person post on Kevin M.D. titled “Why this medical student found primary care awesome, and boring” suggests that, even if we lifted median income for primary care doctors to, say, $250,000, most still  wouldn’t choose family medicine.

Make no mistake: I am not suggesting that primary care is “boring.” Done well, it  engages the finest minds (not to mention the stoutest hearts). The family doctor is a generalist who must know a great deal about everything. 

But the post on Kevin M.D., reflects the reality of how many of today’s medical students view family medicine. (This is in part, because, in most of our medical schools, primary care is granted far less respect than the sub-specialties.)

By contrast, nurses are eager to go into primary care, and  in October of 2010, the National Academy of Sciences’ Institute of Medicine (IOM) issued a report endorsing their role.  The IOM found no evidence that the way NPs practice endangers patients and concluded that “now is the time” to allow nurses to practice to the full extent of their education and training without limitations by doctors.

The IOM recommended that state legislatures revise laws and regulations to let nurses expand their roles, and urged the Centers for Medicare and Medicaid Services to clarify that hospitals participating in the Medicare program must allow nurse practitioners to have clinical and admitting privileges and to be eligible to be on the medical staft.  At the federal level, the IOM suggested that the Federal Trade Commission should identify state regulations related to advanced-practice nursing that have an anticompetitive effect without contributing to the health and safety of the public..

Meanwhile, the revolution already has begun on the ground.  In a paper that focuses on “Implementing the IOM Future of Nursing Report,” RWJF observes that at Health Partners in Minnesota, (a health plan that garners high ratings from patients) nurses “once defined their roles as supporting particular physicians. Today their roles have been re-defined   . . . HealthPartners hires NPs, physicians, and physician assistants to work as primary care providers.

Health Partners “also hires NPs to diagnose and treat common conditions via the Internet . . . . For primary care, this meant replacing a reactive, visit-focused approach with what HealthPartners calls the Care Model Process” . . . a highly respected model, which emphasizes the delivery of evidence based care to an informed and activated patient by a team of prepared and proactive practitioners.”

But will patients accept nurse practitioners? Health Affairs’  policy brief reports that “patients seeing nurse practitioners were found to have higher levels of satisfaction with their care.”   If many patients are happy with NP’s, they will choose them, and acceptance will continue to grow. Patients, I think, will settle the matter.

If patients are wrong (and, let me stress that “patient satisfaction”  is just one measure of healthcare quality), then critics will need to come forward with medical evidence showing that NPs are undermining patient safety.l.

At this point, few doctors argue that NPs cannot enhance care when working alongside physicians. Nevertheless the question remains: should NPS work alone?

 In my next post on Nurse Practitioners, I will tackle that question. My initial response is “No caregiver should work alone.”  But that is a simple response to a complicated problem.


50 thoughts on “A Doctor Confides, “My Primary Doc is a Nurse”

  1. I’ll have to get to the details of your post later, but meantime I have included it in my “Morning Reading” notes for today.
    I have no idea how many people may look at my new blog but as we both know, every one counts.

    Every time I see another reference to a doctor shortage being blamed on ACA my response is two-fold.
    First, if America’s health care is all it’s advertised to be by the medical establishment, how can there be a “doctor shortage”?
    And what are all the technical and nursing people anyway (those who do the everyday caregiving and actual patient contact)… chopped liver?

    Keep up the good work.

    • In you article you asked the basic question: “Should NP’s work alone?” and the answer is… of course not!

      In an ever changing medical world that is constantly being pulled between patient needs… and corporate profits… there needs to be balance and oversight.

      The problem is that while its ecomonically prudent to pawn off certain basic health care needs to NP’s, at some point patients need guidance and healing from an experienced medical professional…. and that medical person should be a doctor… and not an underling.

      I say this because I recently experienced a situation with my mother where we were led to believe… by a doctors assistant… that she may be experiencing symtoms consistent with adult onset diabetes. The news of this sent my mothers blood pressure raising,

      When the actual doctor examined her, it turns out that she was just dehydrated… but that initial wrong diagnoses was enough to convince me NOT to go back to this particular doctor based on the incorrect initial diagnosis from the NP.

      I understand that NP’s are vital and playing an ever increasing role in todays medical profession… but lets not just eliminate the experienced doctors just yet!

      • Ranmsey–

        I understand why you are concerned by what happend with your mother.

        This is just one story about one patient.

        I totally believe that what you are saying is totally true.

        But we have research looking at thousands of patients revealing that
        when Nurse practioners offer primary care, on average the results are just as good.
        Sometimes they are better because NPs are more likely to spend time listening to patients . . .
        At the same time when NPs can’t diagnose a disease they are generally good at passing the case on to a

        Do we want MDs or Nps? It’s a tradeoff–Because of differences in their training MDs have certain strenghts
        NPs have certain strenghts.

        Without question MDs should be caring for the most complicated cases–the ones that are hard to diagnose and manage .

        Ideally MDs and NPs would work together.

        But many MDs won’t work in the low-incom neighborhood clinics and poor rural areas where Nuse Practioners
        provide care. Even if we create more MDs they still won’t want to work in these places.

        This is why we need more NPs as well as more doctors willing to work in the places where most doctors do not want to serve.

        • It’s beyond aggravating to hear that someone will write off a certain type of practitioner (or anything for that matter) because of one bad experience. As a RN I have had multiple encounters with patients that have had horrible experiences with doctors and most of the time their poor care is the reason that the patients are in the hospital to begin with. Still, a large portion of those patients do not write off doctors completely, but instead they search for a new physician. The general public is much more willing to write off NPs because of the general (mis)belief that nurse practitioners are not as skilled or educated as doctors. Though we do not go through the same hazing or educational program we are still comparably skilled at treating patients as evident by the research! Additionally, most NPs have had direct patient care experience as RNs where they were the first line of response for their patients.

          • M–

            You are right–nurse-practitioners tend to be under-rated. A good NP can handle a great many situations.

            My daughter had a baby two years ago and chose to have a nurse-midwife deliver her baby. Three nurse-mid-wives followed her through her
            pregnancy, and one deliver the baby. (Their practice included OB-gyns’–one was at the hospital at all times, so if they ran into a major problem, and
            she needed a C-section, the Ob-gyn could do it. )

            She was very happy with the nurse-midwives. While she was pregnant, they spent time answer her questions. After she had the baby, they visited her in the hospital.

            Over time, more and more people will be treated by NPs–and will trust them more and more.

            This is part of what reform is all about–changing our medical culture. But it will take time.

      • You said it was the doctors assistant who gave your mother unnecessary concern and then proceeded to say it was an NP. Well there’s no such thing as a doctors assistant. There’s a medical assistant, who has VERY basic associate level medical training and who should not be diagnosing or treating anyone, a physician assistant, who has a masters level in medical education, or a nurse practitioner, who has a masters or doctorate level of medical training. So who was it? A lot of issues come from patients not understanding who they are talking to and how much training each person has.

        • Get your facts–

          You are right — it is very important to ask “Are you a nurse or perhaps a nurse practitioner?” You can do this politely
          But it is important to know how much training someone has before taking everything they say at face value.

          IF you’re not comfortable about titles, just ask for the person’s name, then have a friend or relative ask the nurse’s at the desk: “My mother was just talking to Joe Gordon. Is he a nurse, an intern, a nurse practioner??”

  2. Thanks John.
    And you’re right –doctors are not the only “caregivers.” Much of the work of preventive care and chronic disease management is done by nurses, knowledgable pharmacists (who often give customers very good advice), technicians, psychologists and counselors (who help people with drug and alcohol problems.)
    Doctors don’t have to do everything–nor should they. Educating a doctor is a very expensive process. Med school tuitiion is very high, but it doesn’t cover the actual cost of producing an M.D. Medicare pays for it, and as we all know, Medicare cannot afford to foot the bill for educating more doctors unless we really need them. I’ll be writing more about this in the post about whether NPs should run their own clinics.

    • Without question. And these days, many doctors realize this.

      But there are also places where doctors won’t go–and where NPs will.
      In those places, NPs run clinics and work with other NPs

  3. In case you write more on this topic, the designation is “physician assistant” and the plural is physician assistants. There is no possessive (it is not physician’s assistant or physicians’ assistants, for example) as these professionals are not assistants to the doctors. They are practioners in their own right. It’s a distinction worth noting.

  4. Maggie:

    I can think of 3 PAs who took care of me after surgeon David Brown at MedCentral was done with me. Brian, Jessica, and one other were all in attendance at one time or another and finished the job Dr. Brown had started. I liked talking to them as they had more time to spend with me. They understood statistical analysis when they were adjusting my warfarin levels. Being the stats guy I was I would offer suggestions after each reading of where the next dosage should be set. Jessica suggested 2mg dosages which I smiled at because it made statistical sense to the adjustments.

    My daughter is heading in the direction of these young practitioners.

  5. Don’t forget about dentistry and dental shortages and excess costs. Similar extenders are badly needed here as well and now!

  6. NG–
    What you say about dentistry makes perfect sense.
    “Extenders” could no doubt do more than cleaning; they could fill cavities and probably more . . ..
    If I had an abscessed tooth I would want to see a dental surgeon, but otherwise, no doubt we should be training “extenders.”

    Yes, statistics courses are required for NPs.
    People don’t realize how rigorous the training has become. . .
    And good for your daughter!

  7. My mother was an NP for most of her working life and I can tell you from first hand experience if you dont get in with the right medical group you could be in for a tough time. For years she worked with an older doctor who was not threatened by her and gave her the responsibility for handling his patients and pretty much running his office. When he retired the new group was not as interested to have her run things like the old administration and greatly reduced her work load in large part because they felt threatened. If you want to be a career NP. you really need to find the rght group of medica professionals to work with who understand how you can be of value to their practice.

    • Dazzy–

      That’s a very good point.

      These days, I think it’s getting easier to find
      places that make good use of NPs and PAs– Group Health Coop in Seattle is one example.
      Though acceptance of PAs varies greatly by region.

      Its sounds as if your mother is someone who would be capable of managing her own NP clinic (if she lived in one of the 17 states that allows this.)

      She was lucky to find an older doctor who understood her abilities and wasn’t threatened.
      (Reserach shows that doctors who entered med school before roughly 1980 tend to be more liberal–in many
      ways than docs who went to med school in the 1980s.

      That 1980s generation of docs didn’t see reform coming and many of them are not happy with the changes.

      People who entered med school in the 1990s knew that things were changing– managed care, and Clinton’s attempt at health care reform which many thought would succeed. They’re not as surprised by the changes we’re now seeing, and in many cases welcome them.

  8. I always laugh when I hear NPs are going to take over primary care. Let me tell you a little story.

    New Mexico gave complete 100% independence to NPs in 1995. The governor said that giving NPs independence would result in a flood of NPs setting up their own clinics in rural areas and eliminating the shortage of PCPs in that area.

    Guess what happened? Absolutely nothing. The NPs ran to live in Santa Fe and Albuquerque, and completely ignored the rural areas.

    There were a total of 27 primary care clinics in federally designated rural areas in 1995, and 2 of them were staffed by NPs.

    In 2013, guess how many there are? Total of 29, and 3 of them are staffed by NPs.

    Yeah those NPs really came flooding into the rural areas to solve the PCP shortage didnt they?

    Maggie doesnt understand the mindset of NPs. They are employees. They have zero interest in starting up their own clinic or investing in a rural area. All they want to do is work a cushy 9 to 5 job under a doctor in a big urban clinic. Most of them refuse to be on call at all, and you CANT do that and work in a rural area.

    One more thing — most DNP programs are 100% online with no hands on training whatsoever. Univ of South Alabama is a good example — they handed out over 700 DNP degrees last year, all of them earned completely 100% online with no clinical training component. Programs like South Alabama are creating DNP diploma mills, and their degrees are the same as you would find in a cracker jack box. And yet Maggie wants us to call these people “doctor”? What a joke!

    • Vanessa–

      You offer “a little story”

      That’s called an anecdote.

      As an alternantive, let me offer some facts: “Furthermore, non-physicians often serve as the primary medical provider in rural and inner-city areas. Nationally, 15 percent of all physician assistants practice in rural areas, and often the PA is the only medical provider in the community.7 According a 2009-2010 national survey from the American Academy of Nurse Practitioners, approximately 35.3 percent of nurse practitioners work in inner-city locations while 17.8 percent practice in rural areas.8 These are not “cushy” jobs. The numbers are from the U.S.Dept of Health & Human Services

      NPs are twice as likely as physicians to be willing to practice in rural areas: “18 percent of nurse practitioners practice in rural areas, compared with 9 percent of physicians in rural practicestp://nhsc.hrsa.gov/downloads/nhscbackgroundernpspas.PDF

      One reason more NPs don’t practice in rural areas is that some states require that a physician be present part of the time–or be practicing within 45 minutes of a remote rural area. “Since Texas requires that nurse practitioners have both their prescriptive authority and ability to diagnose delegated to them by a physician and to have a physician present once every 10 business days if they practice in medically underserved sites, it is more difficult for nurse practitioners to fill these gaps. Nurse practitioners have been forced to shut down practices and leave patients with no health care provider when physicians are not willing to meet these requirements.http://www.statesman.com/news/news/opinion/nurse-practitioners-on-the-rise/nRy2F/

      You say there are few NPS workign in rural New Mexico. You give no numbers. Here are some facts:
      First there are NPS in rural NM, but the big insurers won’t let them into their networks and won’t pay them.

      At a conference where exectuives from Blue Cross Blue Shield and Cigna were in the audience, an NP expalined: “Blue Cross and Cigna say they care about the state of health care in New Mexico. We have an extreme shortage of health care providers, yet they continue to ignore the resources of health care providers already in New Mexico. I have submitted my application to the very organization you talked about. Presbyterian and Cimarron have admitted me to their panels, but Blue Cross Blue Shield and Cigna won’t even look at my application because I am a nurse practitioner who does not work with an MD.”

      The Blue Cross Blue Shield and Cigna speakers started to fidget.

      “New Mexico has nurse practitioners in rural areas where there are no physicians, but they can’t treat your patients because you won’t recognize them. I am the only provider in my zip code, which includes more than 6,500 families and 100 businesses. I end up treating many of your patients for a co-pay or for nothing at all because they come to me when they can’t get an appointment with their primary care provider for 2 weeks or they feel too sick to sit in urgent care for 4 or 5 hours.” http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/Smart-Practice-Standing-Up-for-Billing-Authority.aspx

      You say that only 3 of NM’s rural clinics are “staffed by NPs.” This is wrong. Only 3 are run by NPs. This is because the big insurers wouldn’t pay bills from an NP. An M.D. had to be running the clinic. (Recently, insurers in NM may have relented) But all 27 NM clinics have NPS on staff.(For a state with NM’s rural population 27 is good.

      Another NP: “New Mexico law allows nurse practitioners to have independent practice. Since most of New Mexico is rural towns or pueblos ( clinics run by the US Indian Health Service), NPs fill the gap providing care in these areas. I was able to do my clinical rotations in many remote clinics serviced only by NPs. Some clinics were owned by the NPs and others were branches of major health systems. All the clinics had relationships with medical groups and specialists from the closest city, who they could call with any questions. Specialists visited monthly. The communities were grateful to have any healthcare close.

      On ONline NP programs. They have to be accredited (if you want to get a job)
      “An online nurse practitioner degree is a degree that allows nurses to attend school while continuing to work. Many online nurse practitioner degrees are geared toward working nurses who are looking to increase their job opportunities and earning potential. Nurse practitioners are increasingly needed at hospitals and clinics, and it is an area that’s rapidly growing. Nurse practitioners continue with the nursing model when treating and caring for patients. Nurse practitioners build on their knowledge as nurses, and patient care experiences with additional training and courses that prepare them to diagnose and prescribe treatment for patients.

      Is an online Nurse Practitioner degree acceptable?
      “The medical community was one of the first industries to welcome online degrees. Many in the medical field will work in different jobs within the span of their careers. Online programs allow a person who is currently working full time to continue with work while studying part time. This is ideal because students are able to make a living and continue their education for better opportunities and pay. Most jobs in the medical field require ongoing training and certification, so online degree programs are an extension of that additional training. There are numerous legitimate programs for medical assistants, medical technicians, nurses, and doctors to add to their areas of expertise and explore new career possibilities within the medical field. Your focus should be finding an accredited nurse practitioner program that suits your needs. As long as the program is accredited, you will not have an issue finding employment after graduating and completing clinicals.”

      Finally, after completing the program, the student “usually required, to get professional nurse practitioner certification. Through the national board exam, NPs can acquire additional credentials as certified pediatric nurse practitioners (CPNP) or certified family nurse practitioners (CFNP), or other specific types of advanced practice nurse. The American Academy of Nurse Practitioners and the American Nurses Credentialing Center are two credentialing organizations that offer certifications in nursing. These certifications must be renewed every five years in order to continue development within the profession

      I could not find the U. of Albama on thelist of accredited online np programs. And the statement that “most NPS get their degrees online” is False.

      • 100% of DNP programs are online? Really. That is absolutely untrue. Please, Vanessa, provide a citation for that little tid bit.
        I am blessed to be in a specialty which allows me to teach residents. The residents and seasoned MDs see me as a resource. They know my 19 years of specialized experience is invaluable and I am a respected member of the team. (NP)

        • Rebecca–

          The idea of using experienced NPs to teach residents is a good one. Of course experienced
          nurses teach residents all of the time, but usually this is not formally emphasized.
          And sometimes residents resist the notion that a nurse can teach them something–or the
          first-year or second-year resident is just embarassed by how little he knows. Even in their
          third year, smart residents realize how much they can learn from nurses who have been caring for patients for years.

          Rebecca, I’m glad you have such a great job.

          Unfortunately, Vanessa’s comment is filled with misinformation.

  9. Please clarify something for me–When this MD says his “doc” is a nurse, then you mention s/he is a PA, I’m confused. Is that person dually licensed as a NP and a PA?

  10. Lou–

    Good to hear from you.

    No, he or she is a PA.

    But he referred to her as his “doc” because she functions as his primary care doctor.

    At Group Health, where he works, titles aren’t as important as they are at many places. Doctors and nurses treat each other as equally important members of the team. For instance, each morning, doctors and nurses who work together have a 15 minute “huddle” –focusing on what lies ahead that day. Often, a nurse leads the “huddle.” (I’ll be writing a separate post about Group Health soon. Much better outcomes and much higher patient satisfaction and doctor satisfaction than medical centers that place more emphasis on heirarchy.)

    As medicine becomes more and more complicated, reformers have come to realize that it needs to be a team sport.
    You might Google Atul Gawande’s essay on “pit crews” and doctors.

  11. A small point- a PA who worked formerly as a nurse should not be referred to as a nurse as they are very different jobs with very different levels of responsibility.

    The typical PA in 2013 has a science related bachelor’s degree (usually pre-med) in addition to thousands of hours of hands-on health care experience (paramedic, EMT, etc) BEFORE starting an incredibly intense 3 year master’s program to in order to sit for our boards and be granted the title of PA.

    Don’t be fooled by the antiquated title- we are not assistants, we are competent health care providers who do much, much more than treat “minor injuries.”

    • Jason–

      Thank you!

      I have now corrected the post.

      HealthBeat posts are often read 2 years or 3 years after I
      write them. People doing research on a topic discover them on Goggle.
      I see HeatlhBeat as, in part, an archive on healthcare and healthcare reform from 2007 to . . ?
      So it is very important to me make corrections, and to update, whenever necessary.
      I want this archive to be accurate.

  12. Your first sentence should be rewritten so that it doesn’t imply that PAs and NPs are the same thing, or that nursing is the stepping stone to PAdom. Yes, some nurses go on to be PAs but the majority that further their education will become NPs. The PA path is taken by people from many professions. The first sentence(any others throughout the article) should also be edited to say “physician assistant” and not “physicians assistant.”

    • Chris–

      Thank much– As I said to Empeda, I didn’t know that PAs come from so many backgrounds.
      I think the “physician’s assitant problem already has been corrected.

  13. Just a minor correction regarding the role of PAs.The article states ” physicians assistants (PAs) don’t work alone”
    PAs(Physician Assistants) do not need to practice at the same site as a physician or “with ” a physician. They need an association with a physician who does some administrative oversight of their practice but many PAs work alone in primary care practices and rural emergency departments without a physician on site. My full time job is solo night shifts at such a facility. I have not worked side by side with my sponsoring physician of record in months.

  14. One additional clarification: PAs come from many medical backgrounds other than nursing. Some PAs are former nurses but many were previously paramedics, respiratory therapists or other types of health care professionals.
    Emedpa, PA-C, EMT-P

    • Emedpa

      Thanks — I didn’t realize that PAs came from so many different backgrounds. Good catch!

  15. I had a recent visit to the emergency room and never laid eyes on an MD. NPs and PAs were on the floor, but no doctor ever laid eyes on me. I was surprised, as in my mind I thought that the gash on my forehead warranted a doctor’s opinion. When I asked if I would be seen by a doctor, the PA told me that she would be treating me. I realized that I had offended her.

    As a consumer I was surprised not to be treated by a doctor. I was unaware of the greater role that PAs are now playing. I went to an expensive hospital because it was close. It seems to me that reducing the role of MDs is really about increasing profits for many institutions. The savings certainly weren’t passed on to me.

    • David-

      Using PAs is not so much about saving money as making better (and more efficient) use of MDs
      Too often, MDs wind up doing things that PA and NPS could do just as well. In some parts of country, we
      don’t have enough MDs to give everyone timely care. This is one reason to use a PA or NP instead.

      Also it is less expensive to train a PA or NP (less expensive high-tech equipment needed– they are not going to be doing robotic surgery, for instance.) And it takes fewer years.

      We have more specialists than we need in most of the country.

      I woudl also point out I will say thatwhile my son was at Cornell for 5 years (in grad school) whenever he went to the university’s medical service, he only saw NPs. (This includes when he was hit head-on by a car. He was on foot. (When he hit the groudn he managed to position himself in between the wheels, so they didn’t run over his body, but he was pretty badly brusied and scraped.

      He felt comfortable with the care he got– as do most folks at Cornell. And this is a pretty sophisticated community of faculty and students

      Since I’m not a doctor, and didn’t see the gash on your head, I don’t have an opinion as to how serious it was.(Equal pay for equal work– that’s the law.) They won’t be doing some of the things that fetch the highest fees (neurosurgery, hip replacements), but they should be paid what an M.D. would be paid to stitch up your gash, X-ray it etc.

      So this is not about saving money.

      Finally all of the medical reserach (published in peer-reviewed medical journals) shows that outcomes are just as good when NPs handle a case as when MDs handle a similar case. (This is why a place like Cornell woudl use mainly NPs.) Sometimes they are better– NPs are more likely to take a careful patient history–and listen. MDS are trained to spend less time listening, more time ordering tests.

      I can understand why you may have been surprised, but when you think about it, we have assumed , for decades, that MDs have
      god-like, magical powers. (This is not fair to them; sometimes, they just can’t cure you. And yet we expect them todddd
      Finally, the assumption that you need an M.D. is, I’m afraid, at least partially tied up with our cultural bias in favor of men (since majority of NPs are women.) But with time, the culture is changing. Before long, I suspect we’ll have a women president!


      In the future PAs and NPs will probably be paid what an MD is paid for doing the same things.

  16. Once it is required to get a Doctorate for NP, what are we to see of these opinions that NPs are not “as good as doctors”? Will the new DNP give these nurses getting a doctorate the title of Dr.? Or will there still be a lot of skepticism from physicians that the nurses that receive their doctorate do not deserve a title like Dr. I had planned to get a doctorate in the first place for my education because I plan on going into psychology and for the best jobs in the field a doctorate really seems to be a must. I guess I don’t understand now what the benefit to going the normal NP route will be over becoming a physician with the new DNP requirements. Does this mean that the pay is going to increase and NPs will be able to do more stand alone work?

    • Yes, going foward NP pay will go up (“equal pay for equal work” is the law) and they will
      be able to do more independent work while also taking on more reponsibilty when working with doctors.

      On the question of whether they will be called “doctor.” I have a Ph.D. but never identify myself as
      “Dr. Mahar” (Few academics do.) Most people think of a “Dr.” as an M.D. or a dentist.

      For that reason, I don’t think NPs should press to be called doctor. Some people would find it misleading, and
      M.D. would continue to object. It’s just not worth fighting for.

      What is worth fighting for respect, pay in keeping with the work you’re doing, and being allowed to do those
      things that you are trained to do.

  17. I thoroughly respect the work of NPs and PAs but I feel it is slightly misleading when the article claims that the schooling is similar for doctors and NPs. In order to be a physician, you are required to receive a bachelor’s degree before even beginning the four years of medical school (and then the minimum 3 year residency program). To my understanding, NPs are required to obtain a bachelor’s of nursing (which is often done as an undergraduate degree) before completing their advanced 3 year training program. This means a physician requires a minimum of 11 years of training/schooling while a NPs requires 8. I do not feel this was well explained in the article. I feel everyone in the medical field plays a vital role in medicine as a whole and that one position is not more or less important than another but I must ask, if a NP wanted to be a physician or have the privileges/benefits of being a doctor, than why not attend medical school?

    • Kayla–

      Thank you for commenting.

      First, I appreciate your respect for NPs and PAs.

      At the same time, I appreciate your point: as you say, NP’s training is, on average, 4 years shorter than an MD’s training. The MD trains for
      11 years while the typical NP trains for 7-8 years.

      This is why NPs don’t do many things that MDs do. For instance, NPs who are nurse-midwivess do not perform Cesareans. They are not
      trained to perform surgery.

      On the other hand, they are trained to try to avoid C-sections and inductions. When a baby is delivered by a nurse-midwife, the chances of C-sections and
      inductions are much lower. (Docs are trained to be more pro-active. This is, I think, mainly a difference in the culture of med schools vs. schools that train
      nurse-midwives. )

      Infant and mother deaths are no higher when nurse-midwives are in charge. As you might imagine, when mother or child is in trouble, they are quick to
      consult with and bring in a M.D. No one wants to be responsible for such a tragedy.

      There are many other things that NPs and PAs can’t do. I really don’t think that most want to be in over their heads.

      But –We’re not making the best use of our doctors. We are asking them to spend a large amount of their time on administrative tasks (that a clerk supervised by an NP could do) and routine care than NPS could cover.

      Renewing a routine medication, for instance. Or talking to a diabetic patient about what she can do to control her disease. What the patient needs to hear is well known, both among NPs and MDs. Often busy MDs don’t have the time–or the patience– to talk to the patient at length. (Good training in nursing schools emphasizes patience. The emphasis is on “comfort”–even if the patient cannot be cured. Doctors are taught that their job is to cure. .

      Finally, let me suggest that while training for 11 years, M.D.s learn many things that they will never use when they practice medicine. (For example, most will never perform surgery, yet their early training requires one or more courses that assume that they might become surgeons. If we needed more surgeons, this would be a good thing–a way to attract more into that specialty.

      But we don’t. Americans undergo far more surgeriesthan patients in other developed countries, but as Boston surgeon Dr. Atul Gawande has pointed out, there is no evidence that patients in the U.S. are benefiting.
      (Google “Gawande, surgeries and “The New Yorker” and I think you’ll find the article.

  18. With today’s “nursing shortage” and recession, a lot of nurses are graduating with previous degrees. I am finishing with my BSN this December after completing a Bachelors in Biology and Chemistry many years ago. That being said, I’m having a hard time deciding where to go next – NP, PA, or PhD in Biology? I have many choices, and feel as if I could already do the jobs of some NPs and PAs. Now, what do I mean by that?
    Well, this “doctor shortage” has made me schedule my dermatology and endocrinology appointments 6 months ahead of time. My dermatologist, who left a clinic to start her own business and make more money (her words, not mine), hired a PA to do her work while she stayed booked for 6+ months. The PA had a shorter wait list, so I took it. After both, the MD and PA, continuously prescribed meds that were way out of my pay range, I decided to go back to the larger clinic and see another doctor. And I had skin cancer. After years of seeing my original dermatologist and her PA (once), not one time did they take into account my being a ginger as having a higher probability of skin cancer. I felt that was something she should have considered, given her job and the countless times I went to her. I don’t blame the PA, as I can’t find a PA residency for dermatology anywhere (did you know there’s a post MSN in dermatology now? add another year or two to those training years!). I felt the MD should have taken the initiative. I believe if I decided to work in dermatology, I would take extra care to look for cancerous marks on people more prone to skin cancer.
    Moving on. When I managed to diagnose myself using WebMD (don’t laugh at the pts who do that btw!), I went to see my internal medicine doctor. He denied my request for a thyroid test and instead suggested I take Prilosec. After demanding the test and saying I’ll pay out of pocket, it turned out I had an autoimmune disease… of the thyroid. Go figure. Before this appointment, I had spent two days trying to find an endocrinologist, but none in this city accepted new patients without referrals. Now, I’m still waiting 4-6 months to see my endocrinologist for a check up. If you know anything about thyroids, you should know that a lot can change within 3 months of diagnosis and beginning meds.
    My point is. No one is perfect. Most of my medical experiences with doctors have been horrible: missing a cancerous growth even though I’m ginger and obviously needed a yearly check up, being told to take meds for what I knew was not heart burn, and waiting forever to see how my new medication has impacted my organ that decided to fail me.
    I believe I have seen each of these doctors enough times to understand the jest of their 15 minute social sessions. How can a NP or PA be any worse in their place?
    I think the problem behind the the whole MDs vs PAs or NPs is that medical school is just too damn expensive. Maybe if that was lowered, and medical insurance for MDs were lowered, then their pay could be lowered. Doctors ask “Why did I go to medical school if an NP could do my job?” How about the $50-100k pay difference? Why not keep doctors in the surgical and highly specialized areas, while the ones who sit in the clinic and charge your insurance $300 a visit go to a lower paid worker who should, in return, save money on the patient.
    I agreed with a post earlier where someone said they missed the savings. When I went to see an ENT about getting my tonsils removed (btw no one in the clinic could tell me how much it would cost out of pocket), I wasn’t given the option of who I wanted in the surgery room. If I had an option, I’d go with the CRNA instead of the anesthesiologist. Patients should be given choices on their healthcare providers and be able to save money by not having to choose the more expensive ones.

    • Netune–

      You make many good points here.

      The second time I saw my dermatologist she noticed two small spots on my hand, took samples, called to tell me that it was very early stage skin cancer, and made
      an appt. for me to come in to have them burned off.

      Each appt was only about 15 minutes, but she doesn’t spend anytime chatting, uses a PA (in the room with her) to take notes while she’s examining me– and the PA orders any
      medications on the computer during the appt. Using a PA costs her money, but saves her time. She also doesn’t overbook–I never wait more than 10 minutes when I go in.
      She takes virtually all insurance (including the insurance that my daughter, a public school teacher, gets through the board of ed. Many doctors don’t take it. )

      How does one find a doctor like this? I think it’s trial and error. I had been going to a dermatologist who did over-book, spent about 4 minutes with me (and everyone else), etc.

      I found the new dermatologist just looking at my insurer’s website.

      I also found an excellent eye doctor on a recommendation from a neighbor across the hall who I don’t even know. Again, pure luck.

      My feeling is that we all need to “shop” more for doctors. Probably one in 10 in excellent. (Just as one in 10 plumbers, or journalists, or teachers is excellent.)

      Finally, I live in Manhattan where there are so many specialists that it is easy to get an appt. even when you’re a new patient.

      P.S. I wonder if you really should wait 4-6 months to see your endocrinologist. I would call around, explain that you have been tested and have an autoimmune disease of the thyroid.
      Or find a well-connected PCP (one who knows many specialists) who will give you a referral as a new patient.

  19. This article is misleading. First Docs study more in length. They go for 4 yrs of undergrade training + 4 years of medical school + atleast 3 years of residency – total 11 years.

    The place where I am working after 12th grade you can get nursing diploma in 2 years. NP/PA does not involve residency at all.

    I work with NP/PA and at times they can handle issues but nowhere they can handle complex medical problems. When you ask physiology or why this problem is happening they do not know.

    They know that they can give Zofran for Vomiting but how it works they do not know.

    Talking about DKA – they are clueless. I recently had to teach one of them importance of anion gap.

    They can take care of day to day simple clinic problems by giving mumbo jumbo of antibiotics, inhalers, antiallergics etc but certainly no way any way closer to doc.

    The doc who confided that his PMD is NP because he knows that even if NP screws up he can fix it for himself. Not so good for general public.

    This article is more about politics and I think you are good at that.

    • Srid–

      We know that the number of years a doctor trains has little to do with how well he cares for his patients.

      Consider the number of patients killed by preventable errors–often a combination of errors committed by several doctors, all of whom had years oof education.

      Today the vast majority of NP’s are getting PHd’s–not two year degrees.

      And their training teaches the things rarely taught in medical school: the importance of listening to patients.

      When nurse-midwives deliver babies, outcomes are better (both for the child and the mother) . They do not induce delivery.
      And of course, they dod not do C-sections (are not trained to do c-sections.)

      Instead, they are willing to wait and let nature take its course.

      In Europe the vast majority of babies are delivered by nurse-midwives– and the evidence shows outcomes are better.

      Finally, your arrogance suggests that you are a doctor who does not listen to patients–or nurses (who often know more about the patient because they spend more time with them.)

      For this reason you are exactly the type of doctor who is most likely to be sued for malpractice.

      What you know (or think you know) about physiology is much less important than who little you understand about other yuan beings.

  20. Btw, hospitals are hiring NP/PAs for cost cutting. Time and time I have to change discharge plans because NP/PAs have been pressured to discharge quickly and they do come under that pressure but physicians can advocate longer stay for right patient and argue against EHI who remotely decides who stays how long.

    • Srid–

      A great deal of research shows that you are mistaken. Outcomes are just as good when NPs/PAs care for patients.

  21. If you took a hospital and removed all the nurses, what would happen? Could Dr’s (M.D.’s) take care of the patients? Ask yourself the opposite question. When you are dying do you call a Dr (M.D.) or do you call 911 (Paramedics, EMT’s)? When you crash in the hospital, who responds? Who does CPR? Who gives the critical care meds? Who runs the ACLS protocol? When you see the Dr (M.D.) how much time do they spend with you, how much of what you have to say is heard? When you are in need who is there? The only thing wrong with nursing, nurse practitioners, DNP’s etc… is the title. Truth is if nursing and medicine were all in one kaleidoscoping practice (which they are anyways) we wouldn’t be having this discussion. The ongoing debate is an asanine one. We are all in the same boat, with the same objective. If you don’t like nurse practitioners don’t see one. Good luck with that, by next year primary care doctors will be 90,000 in the hole. Perhaps what the AMA ought to consider is encouraging physicians to go into primary care and/or joining forces with nursing and unifying into one organized (standardly trained) and well regulated unit. Call yourself whatever you want as long as patients are taken cared of.

    • Franklin–

      Doctors need to realize that these days, medicine is a team sport, and M.D.s are just one part of the team.

      Unfortunately, the AMA is a guild that tends to favor specialists and specialist care (which brings more $$$ into medicine)

      But the ACA aims to change that–by making preventive care free. This means that many more Americans will see doctors, nurse
      practitioners and others who provide preventive care. (I would like to see licensed, well-trained physical therapists included.)

      Less surgery, fewer hospitalizations, more care provided by NPs, Pas, and family docs. This is the future of medicine.

      Btw, primary care docs are not so badly paid– median income is now over $200,000. Half make more.

      Palliative care specialists and pediatricians make significantly less . .

  22. Great article and interesting discussion and feedback. Especially Srid and Vanessa’s enligthening positions. I have been an Advanced Practice Nurse since 1999. Prior I received my Associated then Bachelors over a period of time while i was raising my children. That being said, during those years I worked in critical care at the major teaching hospital. The nurses were incorporated in daily rounds and the interns learned to treat the nurses respectfully because the attendings did so themselves. I then ran the ICU/CCU/ER and went on for my Masters as an NP. I have to say that while i can’t count 11 years of ‘med school’ I can say my 9.5 years of classroom education was thorough and taxing. Nurse Practitioners actually do have clinical residencies, (**responding to Srid) as do the clinical tracks of Doctorate NP degrees. In fact UNC or Duke doesn’t even allow online work–But i digress–as an NP I went on to work in Nephrology for 6 years, with a caring partner (graduated #1 from TUFTS/ declined the Harvard admit classmate and dear friend of Burton Rose–**i’m sure you use uptodate) who never once dismissed or didn’t acknowledge what i brought to the table from my past life and nursing experience. Which as a now INDEPENDENT nurse practitioner, who works solo and teaches medical students and supervises residents, see that what my former partner gave me was a gift. Learning to be humble in any profession goes a long way–much more value that the ever fascinating anion gap (which is useful in a handful of circumstances and is now calculated for you)— perhaps Srid, learn to be a team player and step off your podium. It takes a village–arrogance has no place in your doctoring. An understanding of the AG makes you no better than the person standing beside you–NP/PA/DNP or RN.

    • Elizabeth–

      Thank you very much

      You and people like you represent the future of medicine.

      The fact that you are now teaching medical students and supervising residents is wonderful: they
      are learning, from the outset, that residents and students can learn from experienced nurses.

      I have always felt that med school puts to much emphasis on “curing” the patient. Of course, it’s
      wonderful if that is possible, but sometimes it isn’t. This doesn’t mean the health care provider has “failed”–
      he/she is still needed to “care” for the patient. And nursing school tends to emphasize “care”.

      You’re right: arrogance has no place in doctoring. It’s bad enough to be sick; having to deal with someone who is rude just adds to
      the patient’s anxiety.

      I don’t know if you have ever read Dr. Atul Gawande’s writings (his first book “Complications: A Surgeon’s Notes on
      An Imperfect Science” is wonderful as is his latest book, “Being Mortal.” His humility shines through the pages.

      Going forward, I am hopeful that medical education will change to emphasize teamwork and patient-centered medicine.

  23. “Doctors are worried about paitient safety”? Since when? Doctors are worried about their income going down and they should be. They have been ripping people off for a long time and have a monopoly on writing prescriptions so we patients have no choice. A nurse practitioner might offer a cheaper alternative. I’m sure the making a PHD a requirement was to appease selfish arrogant doctors.

    The truth is that most doctors are obsolete these days. Diagnostics are done by the lab or the imaging center. Nurses and assistants perform injections. Pharma companies make the pills. Doctors are just there in the middle, in the way. Arrogant, overcharging pigs that hold us to randsom with the prescription pad.

    Doctors are generally that breed of compliant nerds from school who are incapable of free thought. They were book smart but never really intelligent. American doctors in particular are just terrible but for some reason, they think we need them. Other than surgeons, what do doctors do these days?

    This article talking about “the success of our model” makes me laugh. What doctor ever follows up with their patients to find out if their treatment had long term success? The answer is none because they aren’t incented to care as they get paid either way. It’s a cushy gig and I for one hope it doesn’t last.

    It is time to let patients choose their own treatments, order their own tests and have a say in what happens to their bodies. Doctors can’t be trusted.

    • Patients are not in a position to choose their own treatments or order their own tests. Medicine is an extremely complicated science– as complicated as the human body–and it is shot through with ambiguities.

      You need someone who has been to med school to explain the risks and benefits of various treatments. If your doctor doesn’t do that, find another doctor!