The Advanced Nurse Practitioner Provider Specialists Experiment

[LiamNeesons]

You hate nurses? I hope you learn to keep that contempt in check when you're actually working with them (getting that real world experience you lack). If you don't, you're going to be in for some difficult years ahead of you. It takes cooperation between disciplines to get patients well and discharged home. Doctors don't do it all.

Hate is an awfully strong word, particularly for someone who has no working knowledge of the day to day business of hospital life.

Sorry, I should have clarified. I have a strong disgust towards nurse practitioners, people who are simultaneously arrogant and ignorant. People who take short cuts when they have reached their potential.

I too hope that in time I will accept the fact that irrational human beings cannot be reasoned with. However, in the meantime, I will probably still suffer from night terrors and uncontrollable shaking at the thought of advanced nurse practitioner provider specialist orthodontist dentists.. analysts.

If only I had dropped out of medical school to get more real world experience in doing what I'm told... Perhaps then I could handle the cognitive demands of a physician.

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[DermViser]

No, no...Heme/Onc.

Doing a basic H&P or actually administering chemo?

 

[tdram]

Sorry, I should have clarified. I have a strong disgust towards nurse practitioners, people who are simultaneously arrogant and ignorant. People who take short cuts when they have reached their potential.

I too hope that in time I will accept the fact that irrational human beings cannot be reasoned with. However, in the meantime, I will probably still suffer from night terrors and uncontrollable shaking at the thought of advanced nurse practitioner provider specialist orthodontist dentists.. analysts.

If only I had dropped out of medical school to get more real world experience in doing what I'm told... Perhaps then I could handle the cognitive demands of a physician.

Seconded.

I think we should just let MBAs and marketing guys be doctors too, because it's all about patient satisfaction, and who's gonna satisfy you more than a smooth talking businessman or marketer?

 

[Mad Jack]

What's scary is that as "smart" as the guy who made the Vox video is: 1) He doesn't realize those studies are nursing sponsored studies with soft metrics (BPs and HgA1C numbers -- instead of something like mortality) on short time frames (or maybe he knows but doesn't care) and 2) doesn't realize that NPs are asking for equal reimbursement as physicians like they've gotten in Oregon.

Vox is liberal BS, Reason.TV is libertarian BS (deregulate everything, let the consumer decide ), and that last video looks like it was just some student nurse's graded project. All have a few things in common. 1) They don't care about the studies. Liberals want nurses to gain power so they can cut down physician incomes and make single-payer happen, libertarians want to deregulate everything, and nurses want more power. 2) They don't care about the reimbursement. Liberals want to add competition, then ratchet down reimbursement across the board, libertarians want competition and think the market should sort itself out, and nurses just want more money by virtue of greater practice rights so they'll do whatever they've got to get it.

 

[DermViser]

That's interesting... I thought the whole purpose of the NP was to solve the crisis of lack of access in primary care. At least that's what all the NPs I know seem to be saying. Last time I checked there was no lack of access to radiation oncologists or dermatologists.

That's bc it was a lie. They don't like primary care - it was a way to elbow their way into specialties like GI, Derm, etc.

 

[Mad Jack]

Seconded.

I think we should just let MBAs and marketing guys be doctors too, because it's all about patient satisfaction, and who's gonna satisfy you more than a smooth talking businessman or marketer?

I'm going to start offering a Doctorate in Satisfactionology for medical business professionals.

 

[tdram]

Vox is liberal BS, Reason.TV is libertarian BS (deregulate everything, let the consumer decide ), and that last video looks like it was just some student nurse's graded project. All have a few things in common. 1) They don't care about the studies. Liberals want nurses to gain power so they can cut down physician incomes and make single-payer happen, libertarians want to deregulate everything, and nurses want more power. 2) They don't care about the reimbursement. Liberals want to add competition, then ratchet down reimbursement across the board, libertarians want competition and think the market should sort itself out, and nurses just want more money by virtue of greater practice rights so they'll do whatever they've got to get it.

I'm cool with it, only if the people that push nurse practitioners use them exclusively for all their and their family's care. No MDs for you. We should do a study on that. How many of the politicians praising NPs do you think actually go to them for their own care?

 

[masaraksh]

Maybe not today, but I wouldn't be surprised if in 10 years the NP is actually doing rad onc. Why not? I mean.. guys.. they have better patient satisfaction scores!!

lol. right. No med school, no residency. Planning RT treatment?!

Heme/Onc I can see. I can see the decision tree being more defined for chemotherapy and perhaps more established protocols can be delegated to non-doctors. Still that just seems cray.

 

[fab4fan]

Part of the problem with medicine is that things that are "zebras" can often present themselves as "horses". The few deaths that will happen will be lost collateral. It would be very difficult to track someone's death being due to 100% incompetence by the NP, although it has been done in one specific case:

http://www.protectpatientsblog.com/2010/12/louisiana_appeals_court_revers.html
The Third Circuit Court of Appeal in Louisiana has ruled the state’s $500,000 malpractice cap to be unconstitutional.

Joe and Helena Oliver had sought relief from the Louisiana Medical Malpractice Act, which shrank the damage award their daughter received for disfiguring injuries from $6.2 million to $500,000.

Their daughter, Taylor, developed severe injuries after she was treated by a “grandfathered” nurse practitioner who was practicing with only a high school diploma. Susan Duhon, a registered nurse practitioner and sole owner of the Magnolia Clinic, treated Taylor for vomiting, nausea and diarrhea. Taylor visited the clinic 32 times, and Duhon prescribed more than 30 medications. Duhon had a statutory duty to consult a physician, but Taylor never saw one during any of her visits.
When Taylor was 14 months old, another hospital diagnosed her with neuroblastoma, a childhood cancer. One of the signs is severe bruising around the eyes, a symptom Taylor had presented with at the Magnolia Clinic when she was 6 months old.

If neuroblastoma is diagnosed within the first year of life, the child has a 90 percent chance of an event-free recovery. But because of the delayed diagnosis, the quality of Taylor's life has been severely diminished. Though she survived the cancer, the tumor caused her head to become misshapen. In addition, her eyes are abnormally large and she is legally blind.

Wait a minute...there's something wrong with that story.

 

[tdram]

I'm going to start offering a Doctorate in Satisfactionology for medical business professionals.

Yeah, just add a part where they can hang around a doctor's office for a few weeks and boom - you've got a primary care provider of the future!

 

[DermViser]

Wait a minute...there's something wrong with that story.

She was grandfathered in.

 

[tdram]

lol. right. No med school, no residency. Planning RT treatment?!

Heme/Onc I can see. I can see the decision tree being more defined for chemotherapy and perhaps more established protocols can be delegated to non-doctors. Still that just seems cray.

Just wait, you'll see. They'll be doing it. And there will be "studies" showing that they're just as effective, etc etc.

We were all idiots to bust our asses in med school and rack up massive debt.

 

[masaraksh]

She was grandmothered.

 

[DermViser]

Just wait, you'll see. They'll be doing it. And there will be "studies" showing that they're just as effective, etc etc.

We were all idiots to bust our asses in med school and rack up massive debt.

They make great cardiologists: http://eurheartj.oxfordjournals.org/content/33/21/2692.full.pdf

http://www.mountsinaiheartnp.org/2012-presentations/10_Role_in_Acute_Cardiac_Care.pdf (See slide 13)

 

[Mad Jack]

Honestly though, DV is right. All of medicine's current problems were caused by their policies. Expanding physician incomes with midlevels, limiting the number of residencies available and the ability for foreign physicians to enter the US, keeping medical student numbers down, etc, led to far fewer physicians than we needed, and a perfect environment for midlevel encroachment to begin. We should have had more medical school seats decades ago. We should have recognized postgraduate training from certain foreign countries via reciprocal agreements (perhaps the Commonwealth countries or the like) and created alternative pathways to primary care practice for foreign physicians from non-Commonwealth countries. Physicians should be providing the services patients need, and nurses should be providing nursing care rather than being half-assed physicians. But the AMA got theirs, and now they're all for pushing Obamacare and midlevels on our generation, because who cares, their portfolios are already stacked high and they'll be off on a beach in South America while we are slaving away in residency and trying to rebuild some of the dignity our profession deserves.

 

[LiamNeesons]

I work in Rad Onc research.

I don't think he meant the RNs/NPs are doing 'actual' Rad Onc. No freakin way.

Rad Onc MDs - plan treatment, manage patients, ...
There are RTTs - who administer the day to day RT fractions
the NPs I've seen at our cancer center are more 'interdisciplinary' - helping the surg, med, and rad onc groups. They see patients in clinic, write up H&Ps, other notes.... basically, the things the attendings can just look over. If needed add an 'addendum to the note'. The NPs will manage basic care issues.

I think I see the problem here. Physicians are still using minions (nurses) to do grunt work. Except now, grunt work includes asking questions, not just giving medications. Nurses think they are practicing medicine because they don't actually know what medicine is. Nurses are really loud, confused people. I think I get it now.

 

[DermViser]

Honestly though, DV is right. All of medicine's current problems were caused by their policies. Expanding physician incomes with midlevels, limiting the number of residencies available and the ability for foreign physicians to enter the US, keeping medical student numbers down, etc, led to far fewer physicians than we needed, and a perfect environment for midlevel encroachment to begin. We should have had more medical school seats decades ago. We should have recognized postgraduate training from certain foreign countries via reciprocal agreements (perhaps the Commonwealth countries or the like) and created alternative pathways to primary care practice for foreign physicians from non-Commonwealth countries. Physicians should be providing the services patients need, and nurses should be providing nursing care rather than being half-assed physicians. But the AMA got theirs, and now they're all for pushing Obamacare and midlevels on our generation, because who cares, their portfolios are already stacked high and they'll be off on a beach in South America while we are slaving away in residency and trying to rebuild some of the dignity our profession deserves.

And if you resist, you'll have the unprofessionalism hammer thrown at you.

 

[fab4fan]

Exactly.

If we assume a Level 3 established patient office visit (the most common E/M code used, comprising almost 50% of all codes), The average reimbursement is about $65 for a physician.

If you fill your schedule with these types of encounters, you can see that by the end of the day you've most likely brought in less than $1000 which will not cover your office overhead. NPs who work independently, in a non-employed position, will see that this is not feasible and they absolutely will start increasing their patient volume and decreasing the amount of time spent with them.

I have no doubt that they will somehow spin this as being better for patient care. LOL

You're right. It will be teaching the patient self-reliance, thereby improving self-esteem, which will result in less need for anti-anxiety or antidepressant meds.

 

[tdram]

Medicine is dying, guys. The future of medicine is a huge mess of people with various degrees, licenses, certificates, etc all fighting to do everything with the consumer increasingly confused about who is who and what. We might even have computers and robots thrown in the mix. A lot of people are going to get sick and die unncessarily, but we won't know why until it's too late and the system is too messy and convoluted to fix. The MDs will get completely drowned out by the noise of hordes of "providers" popping up from everywhere. New generations won't even know what an MD is amidst the alphabet soup of degrees and titles that is healthcare nowadays. The concept of the "doctor" the expert of health will be gone.

The only reason I'm glad I went to med school is at least I'll be able to manage my own health in the midst of this jungle.

 

[aklark]

Training all those NPs and PA's takes up a lot of space too:

http://www.aafp.org/news/education-...0140706preceptstudy.html?cmpid=em_20318028_L1

 

[masaraksh]

They make great cardiologists: http://eurheartj.oxfordjournals.org/content/33/21/2692.full.pdf

http://www.mountsinaiheartnp.org/2012-presentations/10_Role_in_Acute_Cardiac_Care.pdf (See slide 13)

I wouldn't take a single variable Kaplan-Meier, Cox regression analysis too seriously.

 

[fab4fan]

Good point. Clinician is another bad term.

Anyone who cares about this issue, you don't have to spend too much time or money to help the cause. Just do a few things whenever you can
1. Always insist on seeing a physician and not an NP for yourself, your children, etc.
2. Educate your friends and family on the different healthcare "providers" and that an NP is not equivalent to an MD or DO.
3. Educate your fellow med students. You have no idea how many people in my class don't really know what's going on with NPs. Not everyone frequents SDN.

That's not too hard and if everyone starts to do it, we can make a difference.

I already to 1 and 2 for myself, and with friends and family.

 

[aklark]

Good point. Clinician is another bad term.

Anyone who cares about this issue, you don't have to spend too much time or money to help the cause. Just do a few things whenever you can
1. Always insist on seeing a physician and not an NP for yourself, your children, etc.
2. Educate your friends and family on the different healthcare "providers" and that an NP is not equivalent to an MD or DO.
3. Educate your fellow med students. You have no idea how many people in my class don't really know what's going on with NPs. Not everyone frequents SDN.

That's not too hard and if everyone starts to do it, we can make a difference.

Why? I'm not an NP Kool-Aid drinker by any means, but let's say my kid's MD's next opening is mid-August. The office NP can see us tomorrow morning. If I'm taking him because he has worsening eczema and I just want a prescriptino for a stronger steroid and a few suggestions, I value the convenience. It's not as simple as "NEVER SEE AN NP FOR ANYTHING!!!" Same with midlevels in the ED. EM residents aren't missing anything when an NP scoops up a patient with a chief complaint like "stubbed toe" or "wants a sandwich." Concur with 1 and 2.

 

[tdram]

Why? I'm not an NP Kool-Aid drinker by any means, but let's say my kid's MD's next opening is mid-August. The office NP can see us tomorrow morning. If I'm taking him because he has worsening eczema and I just want an rx for a stronger steroid and a few suggestions, I value the convenience. It's not as simple as "NEVER SEE AN NP FOR ANYTHING!!!" Concur with 1 and 2.

That's OK, but I would try to see a physician whenever possible, and don't go to an NP that practices independently. It's OK to see an NP that works under a physician's supervision, if you have to. However, if you can choose NP or PA, always go for the PA. In the midlevel world, PAs are our friends and many of them are not happy with NPs expanding like crazy either.

 

[tdram]

If the public decides that NPs can do everything we can do, then we should go back to our schools and boards and tell them to stop making us jump through hoops that others don't have to. It's simply not fair. Why should we go to residency for 3 years to be a primary care doc when an NP can do the same job with no residency? We should let MD/DO grads practice as a Primary doc after a year of internship like in the old days. Is there any reason why not to, in a country that's increasingly content with the NP level of training for that job? Hell, even a freshly graduated MD/DO should be able to handle it better than a fresh NP.

 

[fab4fan]

Doing a basic H&P or actually administering chemo?

After the onc. orders the chemo., the NP sees the patient for subsequent office visits, re-ordering the chemo or adjusting it if need be. She also responds to emergencies in the infusion room or calls if there's a problem, e.g. pt. comes in with temp., productive cough, etc. So she does many of the same things the attendings do, except she doesn't round on pts, take call, do bone marrow bx., do initial consults.

 

[tdram]

After the onc. orders the chemo., the NP sees the patient for subsequent office visits, re-ordering the chemo or adjusting it if need be. She also responds to emergencies in the infusion room or calls if there's a problem, e.g. pt. comes in with temp., productive cough, etc. So she does many of the same things the attendings do, except she doesn't round on pts, take call, do bone marrow bx., do initial consults.

Actually in my hospital all the bone marrows are done by PAs. Attendings don't really do any of them. I'm not surprised if the NPs can do them too.

 

[fab4fan]

lol. right. No med school, no residency. Planning RT treatment?!

Heme/Onc I can see. I can see the decision tree being more defined for chemotherapy and perhaps more established protocols can be delegated to non-doctors. Still that just seems cray.

I would never see an NP for my cancer. Never, nope nuh-uh, no way Jose'.

 

[fab4fan]

She was grandfathered in.

Not with just a high school diploma.

 

[tdram]

I would never see an NP for my cancer. Never, nope nuh-uh, no way Jose'.

Sadly at some point you likely won't have a choice. I'm pretty confident that NPs will be running the healthcare show soon. They are very vocal and unlike physicians, aren't afraid to fight for their needs and wants, and seem to work together for the benefit of the profession rather than trying to outcompete each other.

 

[DermViser]

Not with just a high school diploma.

http://www.courthousenews.com/2010/12/07/32385.htm
"Currently, to qualify as a nurse practitioner, a nurse is required to obtain a baccalaureate of science and a masters of science in nursing," the ruling states. "Although Ms. Duhon did not obtain any degree in nursing from an institution of higher learning, she was allowed to escape the more rigorous requirements enacted by statute with only a high school degree, under the 'grandfathered' exception."

 

[tdram]

http://www.courthousenews.com/2010/12/07/32385.htm
"Currently, to qualify as a nurse practitioner, a nurse is required to obtain a baccalaureate of science and a masters of science in nursing," the ruling states. "Although Ms. Duhon did not obtain any degree in nursing from an institution of higher learning, she was allowed to escape the more rigorous requirements enacted by statute with only a high school degree, under the 'grandfathered' exception."

How did she get grandfathered in the first place? Were NPs at one point allowed to practice with only a high school diploma?

 

[DermViser]

How did she get grandfathered in the first place? Were NPs at one point allowed to practice with only a high school diploma?

Apparently in Louisiana.

 

[tdram]

Apparently in Louisiana.

That is beyond wack. Sometimes I feel like the libertarians are onto something. Just let everybody loose and the consumer can figure it out. I mean, the licensing authorities are increasingly proving to us that we can't trust them.

 

[fab4fan]

I think I see the problem here. Physicians are still using minions (nurses) to do grunt work. Except now, grunt work includes asking questions, not just giving medications. Nurses think they are practicing medicine because they don't actually know what medicine is. Nurses are really loud, confused people. I think I get it now.

Ehm, excuse me, but I am no one's minion, nor am I loud or confused.

Sadly at some point you likely won't have a choice. I'm pretty confident that NPs will be running the healthcare show soon. They are very vocal and unlike physicians, aren't afraid to fight for their needs and wants, and seem to work together for the benefit of the profession rather than trying to outcompete each other.

I doubt it with my particular situation. I see an gyn/onc who has a solo practice. She's loath to many of the current changes in health care. I would be shocked if she ever took on a mid-level, just knowing how she handles her practice. I'm not saying it couldn't happen. I'm just saying it's highly unlikely.

 

[tdram]

Ehm, excuse me, but I am no one's minion, nor am I loud or confused.


I doubt it with my particular situation. I see an gyn/onc who has a solo practice. She's loath to many of the current changes in health care. I would be shocked if she ever took on a mid-level, just knowing how she handles her practice. I'm not saying it couldn't happen. I'm just saying it's highly unlikely.

What's more likely is your gyn/onc gets eventually bought out by somebody, because solo practices are disappearing fast, the climate is more and more hostile to them every day. Then that entity would likely have midlevels. It wouldn't be up to your doc at that point, it would be up to the MBAs running that company.

 

[fab4fan]

http://www.courthousenews.com/2010/12/07/32385.htm
"Currently, to qualify as a nurse practitioner, a nurse is required to obtain a baccalaureate of science and a masters of science in nursing," the ruling states. "Although Ms. Duhon did not obtain any degree in nursing from an institution of higher learning, she was allowed to escape the more rigorous requirements enacted by statute with only a high school degree, under the 'grandfathered' exception."

LOL..."high school degree." That just boggles the imagination. I'm going to have to investigate that further when I have the mental energy.

 

[tdram]

LOL..."high school degree." That just boggles the imagination. I'm going to have to investigate that further when I have the mental energy.

It's totally insane. Who knows what other crazy exceptions there are in the licensing laws. Who knows how many other people are out there practicing with high school diplomas!

 

[Mad Jack]

LOL..."high school degree." That just boggles the imagination. I'm going to have to investigate that further when I have the mental energy.

Back in the day you could be an RN with only a certificate. Becoming a CRNA or NP only required that you were an experienced RN that completed another certificate to be a NP. So basically you could be an NP with two certificates and no degrees whatsoever.

 

[Mad Jack]

It's totally insane. Who knows what other crazy exceptions there are in the licensing laws. Who knows how many other people are out there practicing with high school diplomas!

There's a great deal of physician assistants practicing with Associate degrees still. Most of them are from Vietnam-era PA programs that trained medics to become physician assistants once they returned home from the war.

 

[tdram]

Back in the day you could be an RN with only a certificate. Becoming a CRNA or NP only required that you were an experienced RN that completed another certificate to be a NP. So basically you could be an NP with two certificates and no degrees whatsoever.

How many NPs are out there practicing with just a certificate and no degrees?

 

[Mad Jack]

How many NPs are out there practicing with just a certificate and no degrees?

Impossible to know, since NP licensing is a state-by-state thing and many states don't make the data available.

 

[tdram]

There's a great deal of physician assistants practicing with Associate degrees still. Most of them are from Vietnam-era PA programs that trained medics to become physician assistants once they returned home from the war.

How is grandfathering even legal? If the licensing body has determined that a higher level of education is absolutely necessary for whatever reason, how can you allow some people to continue to be licensed without it?

It's like determining that a product is dangerous and banning future production, but letting the ones that were already manufactured stay in the stores and continue to sell.

 

[fab4fan]

What's more likely is your gyn/onc gets eventually bought out by somebody, because solo practices are disappearing fast, the climate is more and more hostile to them every day. Then that entity would likely have midlevels. It wouldn't be up to your doc at that point, it would be up to the MBAs running that company.

She's already been approached and has declined. There are only two gyn/oncs in the county, so she's pretty committed to giving patients the care she feels they need. We have these discussions almost every time I see her. Like I said, it isn't impossible, just unlikely.

What I could see happening, before her being bought out, is she and the other gyn/onc merging. He is also independent. They already cross-cover each other for w/e and holidays.

I just cross my fingers and hope things stay the same. I don't think I would get the kind of care she delivers if she were bought out by McMedicine.

 

[DermViser]

How many NPs are out there practicing with just a certificate and no degrees?

I doubt they keep good stats. As years pass, degree creep is common. For example, you didn't need a PharmD to be a pharmacist, you got an R.Ph. Same for PT which didn't require a doctorate.

 

[DermViser]

How is grandfathering even legal? If the licensing body has determined that a higher level of education is absolutely necessary for whatever reason, how can you allow some people to continue to be licensed without it?

It's like determining that a product is dangerous and banning future production, but letting the ones that were already manufactured stay in the stores and continue to sell.

The same way physicians can be grandfathered from Maintenance of Certification requirements.

 

[tdram]

I doubt they keep good stats. As years pass, degree creep is common. For example, you didn't need a PharmD to be a pharmacist, you got an R.Ph. Same for PT which didn't require a doctorate.

I think physicians should institute degree creep too. we should get a separate degree after residency, and be able to tack on BC if we're board certified, like the NPs do. It's not fair that only their names have 1000 letters after them.

Dr. so and so, MD, ENT-BC

 

[tdram]

The same way physicians can be grandfathered from Maintenance of Certification requirements.

Which also doesn't make sense.

 

[Mad Jack]

The same way physicians can be grandfathered from Maintenance of Certification requirements.

Just another example of the Baby Boomers selling everyone else out but exempting themselves. If it's good for us, why not them?

(I am okay with continuing ed and the like, but seriously, how can you justify exempting yourself?!)

 

[tdram]

Just another example of the Baby Boomers selling everyone else out but exempting themselves. If it's good for us, why not them?

(I am okay with continuing ed and the like, but seriously, how can you justify exempting yourself?!)

I agree, no one should be exempt. If one person has to do it, everyone should have to, it or makes no sense whatsoever.