When a nurse is your health-care provider, you’re at risk

[fancymylotus]

I get what you are saying; but being vigilant to get to the bottom of what is going on is different than worrying about always being right. No one ever is always right. No one has been always right. No one will ever be always right. You leave knowing you did the absolutely best that you can do, and you did so with vigilance, competence, and compassion. Then you can put your head on the pillow at night and sleep the sleep of the just. It's this whole issue that is delineated in books like "Learning to Play God," by Dr. Robert Merion--and it evokes more a sense of desperate pride than overwhelming commitment and dedication to people in need.

I don't know. Whatever comes out of this whole "discussion," I am wondering now if in fact I may fit more into the school of Osteopathy. So, perhaps this back and forth has been a good thing, at least for me. I mean, I have never really taken sides on MD vs. DO, b/c that always seemed rather pointless. But if I do lean towards being more holistic in nature, maybe I should apply to more Osteo schools? Seriously.

Naturopathic schools would be your best bet, I think.

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[Psai]

I have never seen someone say so little with so many words

 

[Mad Jack]

2 of our nurse practitioners went to Yale undergrad and Duke for their Doctorate degree and you don't believe they are qualified.

I know a guy who went to Harvard for undergrad and Yale for his doctorate. He's not qualified to practice medicine because those degrees were in English. School prestige doesn't mean a damn thing when it comes to what you're actually trained to do. Nurses are not adequately trained to provide medical care to patients. They are trained to be nurses and provide nursing care. Their nursing training does not adequately prepare them to determine which cases are normal and which cases are not. Sure, they may be able to handle routine as well as any physician, but they aren't properly trained to determine what is and is not routine. That is why they should be supervised by a physician who triages cases that deems which cases are or are not routine, because a nurse will miss the vast majority of the subtle but deadly presentations that infrequently present in primary care.

 

[jl lin]

I have never seen someone say so little with so many words

Too bad you cannot read as quickly as I can type. I will summarize. You attitude is your problem, and my attitude is mine. You might want to get in touch with yours. That's up to you. If not go on and be bitter and continue to bully and allow your crap to run downhill. This should make for a very happy and valuable existence. I took you off ignore, cuz I was really kind of feeling for you. The others like fancy, who I get is well liked, but I have continued to keep on ignore, b/c she adds nothing to the core discussions and uses her little irrelevancies and comments to instigate, and this is not worthy of my time. I give people chances--even when they show me what they are. Yes. I know. "When people show you what they are, believe them the first time." --Maya Angelou. But I also understand that people can be stressed and so forth. My ignore list had maybe 2 people on it since I came here until recently. Only recently have I moved it up to maybe ~ 7 who still participate here. Today it was down to ~ 5. Now it's back up to `6. So, I see you don't really care to discuss. You want to bully and call it venting. OK. Gotcha. Sad.

 

[chasm-e-baddoor]

It means being OK with the possibility of being wrong. Many experienced docs have shared through books and their own experiences how there is some glaring contradictions in education and post-grad experiences, where the culture seems to be, "God forbid that I should be wrong." "If I am wrong, that means that I suck--not a good doctor, nurse, whatever." We don't go out of our way to "be wrong," but in truth it is a vital part of learning and growing and understanding. It's tough also to get around the reality that medicine and also nursing must be both mix both science and art

The problem comes when we lose sight of that and put the science as the end-all/be-all over humanity and people--even as we do so within ourselves.

Here is where youre wrong.

There is nothing OK with a doctor being wrong. The best physician - the one best for the patient - is the one who knows is stuff and is confident in himself. There is no tolerance for error in the standard of care. It's why doctors have to get malpractice insurance. A medical doctor or surgeon who second guesses himself is not the best he can be.

They are expected to follow the scientific method first and foremost. All this other "grow together" stuff is nonsense for the doctor. The only think doctor's need to do is make sure they are always at the forefront.

Science (specifically, the scientific method which forms the basis evidence-based medicine) IS the be-all-end-all when it comes to patient care. A doctor cannot get sued for not being empathetic. In a vacuum and fundamentally speaking, it shouldnt even matter if the the doctor addresses a patient as a number (i'm not saying this is the best thing) as long as the physician is competent as per evidence-based medicine.

 

[Mad Jack]

I truly can't fathom how generalization about people either way will make a difference.
There are compassionate nurses and compassionate docs, and there are those that really don't have a lot of compassion, understanding, insight, and listening abilities--both docs and nurses--and then there are a lot of people that fall in-between these two poles.

I mean the midlevel practice issue, at it's core, is about cutting costs and saving money. At the same time, schools everywhere are just psyched about all that they can make off of such problems. And if anyone really cared about real quality of turn-out--not mere dollars for schools or pushing an agenda, they would not be allowing nurses with very minimal experience entrance into advanced practice nursing programs.

But again, individuals are who they are regardless of if they go through MS programs or nursing programs. If anything, the crucible of each kind of program and practice will ultimately strengthen their underlying character or the programs and real life healthcare experiences will reveal their true characters.

I think one area in which we see where patients care not only about competence in practice but compassion is in the OBGYN field. Some women are hell-bent on having only female physicians--feeling they will be more compassionate, understanding, and it will be less embarrassing for them. But this is not necessarily true. Now, I am not saying there are not truly compassionate female OBGYNs. It's just for me, at least in my area, well, it's usually male OBGYNs that have been more compassionate, tender and not painful upon examination, and more active listeners, etc. And believe me, there have been a few male OBGYNs that I refused to see, b/c they were hurtful upon examination, and they didn't listen, and they just didn't have that sensitive nature women look for in an OBGYN. But remember, in my area at the time, 99% of the OBGYNs were male. So, the compassionate female OBGYNs with the tender touch and ability to actively listen and be sensitive, well, I never got a chance to meet them.

You just can't generalize. I look for certain characteristics regardless of gender, age, race, whatever. It's wrong to generalize. And I would add that it's also unfair to lead a campaign that implies one group of providers are "listeners," so the inference is that the other providers are not. That's really on the manipulative side.

Also, nursing is running off an older model where holistics in medicine were laughed at in education and practice, in general, and where the main focus was on the pathology and not the human being as a whole person--an individual, and there was a sense of distance from this approach. But medical education has improved to look more at the whole person. But the campaign is running off of older models and exploiting this. Actually, the psyh0-social dynamics of this is interesting.

But the other thing that must be considered is that in the educational process for nursing, a strong amount of emphasis is placed on active listening, compassion, avoiding judgment, and holistics. It's there in every course from fundamentals and onward. Now, some of this will just wash over some people, but the points are emphasized repeatedly in these programs. In medical school, there is so much focus on the science and such, that the position of the nursing profession is that holistic approach, active listening, etc is lost. In other words, it would tend to get lost in the great magnitude of material or in is not embedded deeply enough through each and every course in medical education. Again, I think MS programs have worked to try and change this. But the model in nursing begins and ends with the whole human being--not just pathologies. Hence to them, the use of the declarative, "We listen," is not necessarily manipulative. Perhaps nursing needs more education about the MS educational process and their programs. IDK.

Whatever, just sharing from the position I have seen. Regardless, generalizations suck.

A nurse practitioner will actively listen as their patient describes obviously dangerous symptoms that a physician wouldn't miss, then compassionately misdiagnose and offer understanding as they misprescribe a medication that will exacerbate the underlying condition. The nurse feels like they've done a fantastic job, the patient has the warm fuzzes, and everything is working out great, except that whole "the patient got great customer service but was the victim of terrible medical malpractice" bit.

It really makes me want to get a law degree so that I can go to town on NPs. It's an entirely new malpractice market, and you can basically win every case by saying, "So what you're telling me is you missed these key symptoms because they were outside of your training and that you were practicing at the level of a physician even though you weren't one?" It's an untapped market of free money just waiting to be harvested.

 

[jl lin]

Here is where youre wrong.

There is nothing OK with a doctor being wrong. The best physician - the one best for the patient - is the one who knows is stuff and is confident in himself. There is no tolerance for error in the standard of care. It's why doctors have to get malpractice insurance. A medical doctor or surgeon who second guesses himself is not the best he can be.

They are expected to follow the scientific method first and foremost. All this other "grow together" stuff is nonsense for the doctor. The only think doctor's need to do is make sure they are always at the forefront.

Science (specifically, the scientific method which forms the basis evidence-based medicine) IS the be-all-end-all when it comes to patient care. A doctor cannot get sued for not being empathetic. In a vacuum and fundamentally speaking, it shouldnt even matter if the the doctor addresses a patient as a number (i'm not saying this is the best thing) as long as the physician is competent as per evidence-based medicine.

Well, I don't know if I am wrong or not. I am willing to concede that I may be if shown otherwise. The thing is, NO ONE is always right. Vigilance is the key--not getting all up in "I have to be right or I am nothing" mode. That's the downfall, right there. I know full well about no tolerance for error. You forget, it critical care, this standard is as high as it can get. It's more the pervasive attitude that will block coming to true or balance or effective treatment that is the problem. No one will ever always be right. It is impossible in life as well as science.

 

[jl lin]

A nurse practitioner will actively listen as their patient describes obviously dangerous symptoms that a physician wouldn't miss, then compassionately misdiagnose and offer understanding as they misprescribe a medication that will exacerbate the underlying condition. The nurse feels like they've done a fantastic job, the patient has the warm fuzzes, and everything is working out great, except that whole "the patient got great customer service but was the victim of terrible medical malpractice" bit.

It really makes me want to get a law degree so that I can go to town on NPs. It's an entirely new malpractice market, and you can basically win every case by saying, "So what you're telling me is you missed these key symptoms because they were outside of your training and that you were practicing at the level of a physician even though you weren't one?" It's an untapped market of free money just waiting to be harvested.

I don't totally disagree with you. I never have. But also, I have seen this happen with physicians. But it is logical that the more rigorous education and training of a physician would help to prevent what you are saying. I have never argued otherwise.

 

[chasm-e-baddoor]

I get what you are saying; but being vigilant to get to the bottom of what is going on is different than worrying about always being right. No one ever is always right. No one has been always right. No one will ever be always right. You leave knowing you did the absolutely best that you can do, and you did so with vigilance, competence, and compassion. Then you can put your head on the pillow at night and sleep the sleep of the just. It's this whole issue that is delineated in books like "Learning to Play God," by Dr. Robert Merion--and it evokes more a sense of desperate pride than overwhelming commitment and dedication to people in need.

I don't know. Whatever comes out of this whole "discussion," I am wondering now if in fact I may fit more into the school of Osteopathy. So, perhaps this back and forth has been a good thing, at least for me. I mean, I have never really taken sides on MD vs. DO, b/c that always seemed rather pointless. But if I do lean towards being more holistic in nature, maybe I should apply to more Osteo schools? Seriously.

Getting to the bottom of something and worried about being right are the same exact things lol. Both are concerned with finding the solution.

I'm not saying nobody will ever make mistakes, but the GOAL, the gold standard, if you will is to ALWAYS be right. There are surgeons with flawless records. There are physicians who never commit malpractice.

If you did something wrong (as per evidence-based medicine), it means that there wasnt enough vigilance and competence - end of story. **** happens sometimes, and again humans do make mistakes, but it's still a lack of vigilance (which is why malpractice insurance exists).

Osteopathic medical school is the same thing as regular medical school except with OMM lol. DO's and MD's are peers.

 

[chasm-e-baddoor]

Well, I don't know if I am wrong or not. I am willing to concede that I may be if shown otherwise. The thing is, NO ONE is always right. Vigilance is the key--not getting all up in "I have to be right or I am nothing" mode. That's the downfall, right there. I know full well about no tolerance for error. You forget, it critical care, this standard is as high as it can get. It's more the pervasive attitude that will block coming to true or balance or effective treatment that is the problem. No one will ever always be right. It is impossible in life as well as science.

Vigilance = practicing correctly = being right

it's still about being right
Not enough vigilance = not being right

 

[jl lin]

Getting to the bottom of something and worried about being right are the same exact things lol. Both are concerned with finding the solution.

I'm not saying nobody will ever make mistakes, but the GOAL, the gold standard, if you will is to ALWAYS be right. There are surgeons with flawless records. There are physicians who never commit malpractice.

If you did something wrong (as per evidence-based medicine), it means that there wasnt enough vigilance and competence - end of story. **** happens sometimes, and again humans do make mistakes, but it's still a lack of vigilance (which is why malpractice insurance exists).

Osteopathic medical school is the same thing as regular medical school except with OMM lol. DO's and MD's are peers.

No, you miss my point. It is the all hell-bend pride issue of having to be right that is the problem. Vigilance includes balance and reasoning. It's kind of like coming to the place where one looks at the benefits versus the risks, and with either choice the patient and physician lean, they are damned if they do and damned if they don't. There are TONS of moments like that in this arena. Many of them are calls, where even more than one person could be right.

 

[Mad Jack]

I don't totally disagree with you. I never have. But also, I have seen this happen with physicians. But it is logical that the more rigorous education and training of a physician would help to prevent what you are saying. I have never argued otherwise.

I'm just saying, physicians are less likely to make those mistakes. When you have inadequate training, as a nurse practitioner does, and then practice as if you are a fully trained physician, every mistake becomes unforgivable, because almost every one was made out of hubris and a total disregard for the inadequacies of your training.

When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it. That's a big distinction. One is an error, while the other is a result of reckless practice.

 

[jl lin]

I never said they were NOT peers, LOL. I said that the one philosophy in general, or at least historically seems to embrace a more holistic approach.

sigh.

 

[jl lin]

I'm just saying, physicians are less likely to make those mistakes. When you have inadequate training, as a nurse practitioner does, and then practice as if you are a fully trained physician, every mistake becomes unforgivable, because almost every one was made out of hubris and a total disregard for the inadequacies of your training.

When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it. That's a big distinction. One is an error, while the other is a result of reckless practice.

Yes. Overall, I definitely agree with you. I have never disagreed with this. Most NPs that go to MS will agree with you. I have seen that there is much more rigor in MS and also PGE--the latter is really the deal breaker for me. Comparatively, practice hours are not the same for NPs.

 

[chasm-e-baddoor]

I never said they were NOT peers, LOL. I said that the one philosophy in general, or at least historically seems to embrace a more holistic approach.

sigh.

They are peers because they believe in the same philosophy of evidence-based medicine....

Osteopathic schools may blow the horn of "looking at thew hole patient", but that doesnt mean MDs dont look at the whole patient - it's just that it's already implied in evidence-based medicine

 

[midweststudent1]

A nurse practitioner will actively listen as their patient describes obviously dangerous symptoms that a physician wouldn't miss, then compassionately misdiagnose and offer understanding as they misprescribe a medication that will exacerbate the underlying condition. The nurse feels like they've done a fantastic job, the patient has the warm fuzzes, and everything is working out great, except that whole "the patient got great customer service but was the victim of terrible medical malpractice" bit.

It really makes me want to get a law degree so that I can go to town on NPs. It's an entirely new malpractice market, and you can basically win every case by saying, "So what you're telling me is you missed these key symptoms because they were outside of your training and that you were practicing at the level of a physician even though you weren't one?" It's an untapped market of free money just waiting to be harvested.

I think you are so right and I've been thinking this myself--when will the malpractice lawyers realize that NPs practicing autonomously are a tree full of lawsuits that is ready to be picked? The number graduating didn't pick up until recently, but I expect malpractice claims against them to SOAR over the next decade

 

[jl lin]

They are peers because they believe in the same philosophy of evidence-based medicine....

Osteopathic schools may blow the horn of "looking at thew hole patient", but that doesnt mean MDs dont look at the whole patient - it's just that it's already implied in evidence-based medicine

Agreed. I said historically. EBP is only one part of being a physician.

 

[Psai]

Agreed. I said historically. EBP is only one part of being a physician.

A lot of opinions about what makes up a physician from someone who isn't even in medical school

 

[jl lin]

OK Psai. I have worked with more of them than you have over the years, and very closely might I add. Beyond that there are a number of reasons why I should have some insight into this.

Seriously, as I said, you just want to play bully. Kind of sad, but this is the end of the Bully Show here for me right now. Carry on with putting down others or something very close to this in order to TRY and make you feel better about you.

Thanks much and have a great day.

 

[acceptmeplease]

A lot of opinions about what makes up a physician from someone who isn't even in medical school

Deductibles are too high to be burning that hard.

 

[acceptmeplease]

OK Psai. I have worked with more of them than you have over the years, and very closely might I add. Beyond that there are a number of reasons why I should have some insight into this.

Seriously, as I said, you just want to play bully. Kind of sad, but this is the end of the Bully Show here for me right now. Carry on with putting down others or something very close to this in order to TRY and make you feel better about you.

Thanks much and have a great day.

A flight attendant works with many pilots over a career, but beyond deciding not to crash a plane, there's probably not a lot of technical insight gained...cause the drink trolley.

I worked with many rad techs and RTs, but beyond knowing that trach care noises gross me out, and that the portable X-ray is really freaking cool, I don't know a lot about the fields.

 

[W19]

I get what you are saying; but being vigilant to get to the bottom of what is going on is different than worrying about always being right. No one ever is always right. No one has been always right. No one will ever be always right. You leave knowing you did the absolutely best that you can do, and you did so with vigilance, competence, and compassion. Then you can put your head on the pillow at night and sleep the sleep of the just. It's this whole issue that is delineated in books like "Learning to Play God," by Dr. Robert Merion--and it evokes more a sense of desperate pride than overwhelming commitment and dedication to people in need.

I don't know. Whatever comes out of this whole "discussion," I am wondering now if in fact I may fit more into the school of Osteopathy. So, perhaps this back and forth has been a good thing, at least for me. I mean, I have never really taken sides on MD vs. DO, b/c that always seemed rather pointless. But if I do lean towards being more holistic in nature, maybe I should apply to more Osteo schools? Seriously.

When are you applying to med school?

 

[mimelim]

A nurse practitioner will actively listen as their patient describes obviously dangerous symptoms that a physician wouldn't miss, then compassionately misdiagnose and offer understanding as they misprescribe a medication that will exacerbate the underlying condition. The nurse feels like they've done a fantastic job, the patient has the warm fuzzes, and everything is working out great, except that whole "the patient got great customer service but was the victim of terrible medical malpractice" bit.

It really makes me want to get a law degree so that I can go to town on NPs. It's an entirely new malpractice market, and you can basically win every case by saying, "So what you're telling me is you missed these key symptoms because they were outside of your training and that you were practicing at the level of a physician even though you weren't one?" It's an untapped market of free money just waiting to be harvested.

I'm just saying, physicians are less likely to make those mistakes. When you have inadequate training, as a nurse practitioner does, and then practice as if you are a fully trained physician, every mistake becomes unforgivable, because almost every one was made out of hubris and a total disregard for the inadequacies of your training.

When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it. That's a big distinction. One is an error, while the other is a result of reckless practice.

Do you have any studies to show that NPs provide inferior care to MDs? I can count on one hand the number of NP mistakes caught by MDs that I've seen. I've lost track of the number of MD mistakes caught by NPs. You make a lot of generalizations, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." The first and third of those are categorically false. The second one may be true, but I'd like to see some sort of evidence of that.

This is akin to Cardiologists performing peripheral or carotid stents, or any number of procedures being performed by IM/FM to boost their bottom line. They lack the training to do it as well as others (ie surgeons) or take care of their own complications. Physicians do this all the time, it is hardly surprising that NPs will do the same. Hubris is a far bigger problem in the MD community than NP.

 

[Psai]

Asking for studies about something that's difficult to measure is a classic nursing move. Absence of evidence is not evidence of absence. And the studies that have been put out tend to be poorly designed and underpowered. I agree with the rest of your post though, cardiologists should just stick with the heart and FM docs shouldn't be doing scopes imo

 

[acceptmeplease]

Do you have any studies to show that NPs provide inferior care to MDs? I can count on one hand the number of NP mistakes caught by MDs that I've seen. I've lost track of the number of MD mistakes caught by NPs. You make a lot of generalizations, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." The first and third of those are categorically false. The second one may be true, but I'd like to see some sort of evidence of that.

This is akin to Cardiologists performing peripheral or carotid stents, or any number of procedures being performed by IM/FM to boost their bottom line. They lack the training to do it as well as others (ie surgeons) or take care of their own complications. Physicians do this all the time, it is hardly surprising that NPs will do the same. Hubris is a far bigger problem in the MD community than NP.

Just for clarification on the many mistakes that you find from other MDs, are these physicians still in training or attendings?

 

[Mad Jack]

Do you have any studies to show that NPs provide inferior care to MDs? I can count on one hand the number of NP mistakes caught by MDs that I've seen. I've lost track of the number of MD mistakes caught by NPs. You make a lot of generalizations, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." The first and third of those are categorically false. The second one may be true, but I'd like to see some sort of evidence of that.

This is akin to Cardiologists performing peripheral or carotid stents, or any number of procedures being performed by IM/FM to boost their bottom line. They lack the training to do it as well as others (ie surgeons) or take care of their own complications. Physicians do this all the time, it is hardly surprising that NPs will do the same. Hubris is a far bigger problem in the MD community than NP.

The trouble is all the studies to date have been short and performed in low-acuity environments with physician referral available. I've yet to see a long-term (10 years or more) study showing equal outcomes for NPs without supervision that have patients who are of equal acuity to a MD FP. I'd honestly like to see one done. If, at the end of the day, the care is equal after a long-term study, then fair's fair and FPs are officially overeducated I guess. I just doubt that'll be the case.

 

[Baller MD]

Do you have any studies to show that NPs provide inferior care to MDs? I can count on one hand the number of NP mistakes caught by MDs that I've seen. I've lost track of the number of MD mistakes caught by NPs. You make a lot of generalizations, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." The first and third of those are categorically false. The second one may be true, but I'd like to see some sort of evidence of that.

This is akin to Cardiologists performing peripheral or carotid stents, or any number of procedures being performed by IM/FM to boost their bottom line. They lack the training to do it as well as others (ie surgeons) or take care of their own complications. Physicians do this all the time, it is hardly surprising that NPs will do the same. Hubris is a far bigger problem in the MD community than NP.

Do you have any studies to show that NPs provide equal care to MDs?

I can play that game too.

 

[Mad Jack]

Very related to thread. Not that I'm saying nurses are stupid, but the same idea presented applies to incompetence in any given field.

 

[mimelim]

Asking for studies about something that's difficult to measure is a classic nursing move. Absence of evidence is not evidence of absence. And the studies that have been put out tend to be poorly designed and underpowered. I agree with the rest of your post though, cardiologists should just stick with the heart and FM docs shouldn't be doing scopes imo

Do you have any studies to show that NPs provide equal care to MDs?

I can play that game too.

My issue is with the basis for assertions like, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." That is why I asked for studies. @Mad Jack is making fairly outlandish claims about things. I have a fair amount of exposure to NPs and PAs as well as physicians. I have for 4-5 years now. In my experience, the things that he is saying are categorically inaccurate. Saying things that are indefensible with no factual basis is torpedoing his own argument. I've seen an attending physician miss life threatening symptoms that were caught by an NP a few minutes later. This wasn't because a physician forgot something, this is because they missed it.

I am categorically against NPs having independent practice. But, that doesn't mean I throw around completely unsubstantiated claims about mid levels. A far bigger issue is hubris among all providers, something that is in my experience far more prevalent among physicians. MDs do it all the time, going into areas that they weren't trained to do nearly as well as other physicians, a lot of times in the pursuit of higher RVUs. To somehow paint NPs as 'worse' in that area is just plain naive and juvenile.

Just for clarification on the many mistakes that you find from other MDs, are these physicians still in training or attendings?

Both, but I am primarily speaking to attendings.

The trouble is all the studies to date have been short and performed in low-acuity environments with physician referral available. I've yet to see a long-term (10 years or more) study showing equal outcomes for NPs without supervision that have patients who are of equal acuity to a MD FP. I'd honestly like to see one done. If, at the end of the day, the care is equal after a long-term study, then fair's fair and FPs are officially overeducated I guess. I just doubt that'll be the case.

How many NPs have you worked with? How many mistakes have you seen made? Is this purely theoretical speculation on your part or do you have any sort of background/experience/knowledge on this? If the answer is theoretical speculation, I'd stay away from making strong assertions such as, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." as you have no foundation to make such strong claims.

 

[Mad Jack]

How many NPs have you worked with? How many mistakes have you seen made? Is this purely theoretical speculation on your part or do you have any sort of background/experience/knowledge on this? If the answer is theoretical speculation, I'd stay away from making strong assertions such as, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." as you have no foundation to make such strong claims.

I worked at a top 10's teaching hospital for 6 years before I started medical school. We had NPs on staff in the MICU and SICU and the attendings frequently had to correct very serious errors in their judgement. The better ones knew when they were at the limits and would consult with an attending at that point (which is totally fine and appropriate) but it was the ones fresh out of school that were dangerous. I didn't go a shift with a midlevel without having to consult an attending about something in regard to how we should proceed, and that's what firmly cemented my belief that midlevels should not practice independently.

 

[chasm-e-baddoor]

I honestly dont care who is called what and can practice what as long as they are held to the same standard when it comes to malpractice.

But to anyone saying that NP can and should be able to do the same things as a physician, riddle me this - what is even the point of having a physician (MD/DO) - DNP distinction? Why have family practice physicians at all, if the DNP can do the same things for less money and less training? What the hell is the point of investing valuable taxpayer money into funding family practice residencies across the country? What is the point of insurance companies having different reimbursement policies based on residency training? what is the point of having different malpractice laws based on residency training?

Anybody who agrees with this NP independent practicing concept is basically saying that family physicians are obsolete.

I wonder if a NP can manage the several chronic diseases simultaneously afflicting a patient. I wonder if NP has the knowledge to refer to , work with, and communicate with medical specialists, pathology, surgery, etc. I wonder if a NP is astute enough to recognize as many signs and make as many diagnoses as a PCP.

Primary care is underrated and is the welcome wagon for everything else. Despite people with high board scores usually flocking to more lucrative specialties, family medicine is still challenging and the fact that many NP and their supporters think they can fill their role shows how ignorant they are of what PCPs do. To me, the astute family physician impresses me as much as the top cardiothoracic surgeon.

 

[demayette]

Do you have any studies to show that NPs provide inferior care to MDs? I can count on one hand the number of NP mistakes caught by MDs that I've seen. I've lost track of the number of MD mistakes caught by NPs. You make a lot of generalizations, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." The first and third of those are categorically false. The second one may be true, but I'd like to see some sort of evidence of that.

This is akin to Cardiologists performing peripheral or carotid stents, or any number of procedures being performed by IM/FM to boost their bottom line. They lack the training to do it as well as others (ie surgeons) or take care of their own complications. Physicians do this all the time, it is hardly surprising that NPs will do the same. Hubris is a far bigger problem in the MD community than NP.

 

[acceptmeplease]

My issue is with the basis for assertions like, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." That is why I asked for studies. @Mad Jack is making fairly outlandish claims about things. I have a fair amount of exposure to NPs and PAs as well as physicians. I have for 4-5 years now. In my experience, the things that he is saying are categorically inaccurate. Saying things that are indefensible with no factual basis is torpedoing his own argument. I've seen an attending physician miss life threatening symptoms that were caught by an NP a few minutes later. This wasn't because a physician forgot something, this is because they missed it.

I am categorically against NPs having independent practice. But, that doesn't mean I throw around completely unsubstantiated claims about mid levels. A far bigger issue is hubris among all providers, something that is in my experience far more prevalent among physicians. MDs do it all the time, going into areas that they weren't trained to do nearly as well as other physicians, a lot of times in the pursuit of higher RVUs. To somehow paint NPs as 'worse' in that area is just plain naive and juvenile.



Both, but I am primarily speaking to attendings.



How many NPs have you worked with? How many mistakes have you seen made? Is this purely theoretical speculation on your part or do you have any sort of background/experience/knowledge on this? If the answer is theoretical speculation, I'd stay away from making strong assertions such as, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." as you have no foundation to make such strong claims.

So basically we should respect your anecdotal evidence over our own?

That's no fun.

 

[mimelim]

I worked at a top 10's teaching hospital for 6 years before I started medical school. We had NPs on staff in the MICU and SICU and the attendings frequently had to correct very serious errors in their judgement. The better ones knew when they were at the limits and would consult with an attending at that point (which is totally fine and appropriate) but it was the ones fresh out of school that were dangerous. I didn't go a shift with a midlevel without having to consult an attending about something in regard to how we should proceed, and that's what firmly cemented my belief that midlevels should not practice independently.

What I would caution you is that a "top 10's teaching hospital" is not going to attract the better midlevels as they tend to have less money than community hospitals and private practices for ancillary staff. Just like you have ****ty NPs, you have ****ty doctors too. Also, needing to get a consult in an ICU is hardly analogous to a family practice clinic. You clearly haven't met the moonlighting residents and fresh hospitalists/FM people. The stupidest **** imaginable.

 

[mimelim]

So basically we should respect your anecdotal evidence over our own?

That's no fun.

I'm not claiming things like, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." Those are assertions that one makes based on evidence or a healthy dose of experience. That was my issue.

 

[Mad Jack]

What I would caution you is that a "top 10's teaching hospital" is not going to attract the better midlevels as they tend to have less money than community hospitals and private practices for ancillary staff. Just like you have ****ty NPs, you have ****ty doctors too. Also, needing to get a consult in an ICU is hardly analogous to a family practice clinic. You clearly haven't met the moonlighting residents and fresh hospitalists/FM people. The stupidest **** imaginable.

I've met plenty of both. Everyone's stupid, myself included. I just want the least stupid people possible- attending physicians- managing things, rather than some nurse that has 500 hours of advanced practice training.

As to the pay, we attracted a lot of brilliant young NPs and PAs care of our location and decent pay. It wasn't the best, but it was around average, and you can't beat living in the NE and saying you work for *Insert Top 10 Name Here* for a living.

 

[W19]

Here is a typical NP program curriculum: http://nursing.msu.edu/msn programs/Nurse Practitioner Concentration/NP Curriculum.htm
Courses

NUR 802: Theoretical Foundations and Role Development for the Advanced Practice Nurse
NUR 804: Statistics for the Healthcare Professional
NUR 805: Pathophysiology for Advanced Practice Nurses
NUR 806: Research for Practice Nurses
NUR 807: Clinical Decision Making
NUR 809: Applied Pharmacology for Advanced Practice
NUR 814: Health Care Policy and Politics
NUR 820/835: Health Assessment
NUR 821/836: Primary Care Management I
NUR 822/832: Practicum I Primary Care
NUR 823/837: Primary Care Management II
NUR 824/834: Practicum II
NUR 838: Care for Aging Individuals

'Statistics for the Healthcare Professional' ACA biostats--an 8-hour class in med school.

Seriously!

 

[Mad Jack]

I'm not claiming things like, "obviously dangerous symptoms that a physician wouldn't miss"or "physicians are less likely to make those mistakes" or "When a physician misses something, they miss it because they forgot something. When a nurse practitioner misses something, it's because they never learned it." Those are assertions that one makes based on evidence or a healthy dose of experience. That was my issue.

Here's the thing though, physicians are at least exposed to damn near everything in their medical education. They might make mistakes as often as nurse practitioners, but at some point, they learned the thing they missed. NPs don't get a lot of solid pathophysiology in their education, so if they miss something, it is often because they never learned it. An MD might have a small chance of catching it, while an NP will have zero chance.

 

[oldanddone]

*aussie accent and nature show* now we see here the alpha male of the pack rumble in from the kill with blood on the muzzle, asserting his dominance amongst the other wolves who are just less competent, less advanced, just less. the hyenas are keeping their distance, grins wide and eyes watching. there are a few pups willing to assert their status, that will one day be theirs depending on how they specialize whether into alpha or pack.

 

[Instatewaiter]

Holistic... what a ridiculous idea.

Anything that is germane to a patient's medical care is not holistic it is appropriate medical care. Anything beyond that is superfluous.

 

[Mviande29]

I didn't read all the comments, so I don't know if this has been said before.

I showed my sister, the NY NP, this article and she says that the author sounds completely ignorant. She said that NPs only take typical, wellness cases. And in my experience as someone who has lived his entire life in NY, I've only come across NPs working in a primary care offices with a MD in the other room to provide oversight when needed. I don't really see why I would have needed a MD to do a basic work physical.

I think most NPs know that they cannot completely fulfill the role of a family physician, but they were needed to fill gaps. If you're so concerned about NPs serving the basic health needs of areas whose needs aren't being met by a shortage of family physicians, go into family medicine or at least fight to remove the barriers keeping people from going into family medicine....

 

[Mviande29]

The curriculum of NPs in NY is also expected to be extended and it is becoming increasingly more difficult to get into NP programs, with more experience as an RN being required before being accepted. NPs have been adjusting to their expanded roles to ensure that they know what they are doing

 

[oldanddone]

i'd prefer to see np and md given full equivalence - but that must include remuneration and autonomy. if there is anything about np training (i.e. not being funded, or needing to be self-funded, whereas residency is funded) that allows for governmental cheapening and shirking, then that too must be addressed. np cannot be used essentially as 'scab labour' to undercut price. edit: full equivalence predicated on the idea that the two ways of training lead to equivalent outcomes. it would be a rolling back of the flexner report in some ways, acknowledging and legitimizing of many pathways to 'healer' or 'practitioner', but with the caveat to have evidence that there is equivalence. and the caveat as before to not be creating 'scab labour' scenarios.

it used to be that the stated goal was serving the underserved, due to a doctor shortage. but it seems that the rhetoric is more blatant about the 'real' reason, which is undercutting price. nps also are more likely to specialize and to stay in academic centres (i.e. the goal of serving the underserved in primary care did not happen). i'm glad of the challenges in the northwest that now look to block the undercutting of price. however, in times of uncertainty there is a lot of room for power-plays. are the medical and nursing associations ready or are they going to be played off each other like pawns?

i hesitate to use the term 'labour' because being part of a profession was different from the position of 'labour', it had more autonomy. being pushed into a position of labour has a lot of drawbacks. at the same time, we don't organize ourselves for collective power nearly as well as unions. in fact, we generally have taken on a privileged stance of finding unions distasteful. that may become part of our downfall, rejecting the knowledge of the power of collectives and solidarity.

 

[Psai]

Full equivalence is attainable for any nurse that wants to practice medicine. It's called medical school.

 

[fancymylotus]

I didn't read all the comments, so I don't know if this has been said before.

I showed my sister, the NY NP, this article and she says that the author sounds completely ignorant. She said that NPs only take typical, wellness cases. And in my experience as someone who has lived his entire life in NY, I've only come across NPs working in a primary care offices with a MD in the other room to provide oversight when needed. I don't really see why I would have needed a MD to do a basic work physical.

I think most NPs know that they cannot completely fulfill the role of a family physician, but they were needed to fill gaps. If you're so concerned about NPs serving the basic health needs of areas whose needs aren't being met by a shortage of family physicians, go into family medicine or at least fight to remove the barriers keeping people from going into family medicine....

I'm sorry, my state is doing WHAT now? Damnit New York, I love you so much but you allow the stupid **** to happen..

 

[deleted128562]

I didn't read all the comments, so I don't know if this has been said before.

I showed my sister, the NY NP, this article and she says that the author sounds completely ignorant. She said that NPs only take typical, wellness cases. And in my experience as someone who has lived his entire life in NY, I've only come across NPs working in a primary care offices with a MD in the other room to provide oversight when needed. I don't really see why I would have needed a MD to do a basic work physical.

I think most NPs know that they cannot completely fulfill the role of a family physician, but they were needed to fill gaps. If you're so concerned about NPs serving the basic health needs of areas whose needs aren't being met by a shortage of family physicians, go into family medicine or at least fight to remove the barriers keeping people from going into family medicine....

LOL!!!! Lzzzolololllloooolololzz!!! NP's serving basic health needs in areas where there are shortages!! LOLOzzlololLOLOLOzzz!!!!11!!eleven!!

At my institution there is a huge poster with all the pictures of the "advanced practitioners" and what fields they are in. There's a little area in the top left corner with the few people who are in family med, internal med, and peds. The remaining 90% of the poster is dedicated to the people who are working in neurosurgery, ortho, ENT, derm, surgery, critical care, plastics, vascular, etc etc etc.

You think NP's go to school so they can fill shortages in primary care?!?! LOLLOZzoLOLozzoloLOL!!!!

 

[SouthernSurgeon]

LOL!!!! Lzzzolololllloooolololzz!!! NP's serving basic health needs in areas where there are shortages!! LOLOzzlololLOLOLOzzz!!!!11!!eleven!!

At my institution there is a huge poster with all the pictures of the "advanced practitioners" and what fields they are in. There's a little area in the top left corner with the few people who are in family med, internal med, and peds. The remaining 90% of the poster is dedicated to the people who are working in neurosurgery, ortho, ENT, derm, surgery, critical care, plastics, vascular, etc etc etc.

You think NP's go to school so they can fill shortages in primary care?!?! LOLLOZzoLOLozzoloLOL!!!!

I'd be willing to be the number of NP's working in primary care or at "minute clinics" and urgent cares far outnumbers the ones working in subspecialties. Large tertiary institutions are not a balanced sample.

The problem with the argument that NP's can fill the primary care "gap" is that the gap isn't in New York or Boston or LA. It's in rural areas, flyover states, the impoverished south, etc. So while an NP in new york might be working as a PCP, they aren't alleviating a shortage; they are just more competition (and cheaper competition) in an already crowded market.

 

[deleted128562]

I'd be willing to be the number of NP's working in primary care or at "minute clinics" and urgent cares far outnumbers the ones working in subspecialties. Large tertiary institutions are not a balanced sample.

The problem with the argument that NP's can fill the primary care "gap" is that the gap isn't in New York or Boston or LA. It's in rural areas, flyover states, the impoverished south, etc. So while an NP in new york might be working as a PCP, they aren't alleviating a shortage; they are just more competition (and cheaper competition) in an already crowded market.

That is a fair point. But it looks like we both agree on a basic premise - people are not going to NP school so they can fill the primary care shortage. They are going so they can make $$$$ in a subspecialty or practice primary/ urgent care in a desirable location that doesn't really need any primary care help.

 

[acceptmeplease]

i'd prefer to see np and md given full equivalence - but that must include remuneration and autonomy. if there is anything about np training (i.e. not being funded, or needing to be self-funded, whereas residency is funded) that allows for governmental cheapening and shirking, then that too must be addressed. np cannot be used essentially as 'scab labour' to undercut price. edit: full equivalence predicated on the idea that the two ways of training lead to equivalent outcomes. it would be a rolling back of the flexner report in some ways, acknowledging and legitimizing of many pathways to 'healer' or 'practitioner', but with the caveat to have evidence that there is equivalence. and the caveat as before to not be creating 'scab labour' scenarios.

it used to be that the stated goal was serving the underserved, due to a doctor shortage. but it seems that the rhetoric is more blatant about the 'real' reason, which is undercutting price. nps also are more likely to specialize and to stay in academic centres (i.e. the goal of serving the underserved in primary care did not happen). i'm glad of the challenges in the northwest that now look to block the undercutting of price. however, in times of uncertainty there is a lot of room for power-plays. are the medical and nursing associations ready or are they going to be played off each other like pawns?

i hesitate to use the term 'labour' because being part of a profession was different from the position of 'labour', it had more autonomy. being pushed into a position of labour has a lot of drawbacks. at the same time, we don't organize ourselves for collective power nearly as well as unions. in fact, we generally have taken on a privileged stance of finding unions distasteful. that may become part of our downfall, rejecting the knowledge of the power of collectives and solidarity.

Yea, I'd love to see an NP in a general surgery residency not know anatomy.
"Well gee, Dr, in my nursing leadership electives we didn't cover the celiac trunk, but I can prevent the hell out of a fall!"

And these NP-only residencies that you dream of, will they also be taught by NPs who also can't pass medical boards?

Perhaps there will be nursing conferences on weekends where they can learn all of the important stuff that physicians take years to learn.

 

[SouthernSurgeon]

That is a fair point. But it looks like we both agree on a basic premise - people are not going to NP school so they can fill the primary care shortage. They are going so they can make $$$$ in a subspecialty or practice primary/ urgent care in a desirable location that doesn't really need any primary care help.

Agreed. The "fill the primary care gap" line is a marketing tool to make these schools politician-friendly.

Although to be fair, DO expansion has largely done the same thing...