Advertisement

MD Kicks NP Hornet's Nest in NYT Op-Ed — Big Buzz Heard — Physician’s First Watch

Medical News |
May 1, 2014

MD Kicks NP Hornet's Nest in NYT Op-Ed — Big Buzz Heard

By Joe Elia

There are likely to be tempests in your hospital's water coolers over a New York Times opinion piece titled "Nurses Are Not Doctors."

The New York state legislature just passed a bill enabling nurse practitioners to provide primary care without physician oversight. Sixteen other states already give nurse practitioners similar levels of autonomy. Nurse practitioners are helping fill the ranks of primary care providers depleted by the physician exodus to the higher-paying specialties. The essayist, a cardiologist, questions the cost-effectiveness of that strategy by citing a 15-year-old study reportedly showing that the patients of nurse practitioners had 25% more referrals to specialists and 41% more hospital admissions.

The story has received an unusually high number of reader comments. One that resonated with the Times' readers offered a simple solution: if we "pay cardiologists less, then there will be more money to pay primary-care physicians more. Then there will be more primary-care physicians."

Reader Comments (19)

MICHAEL GAREY Physician, Emergency Medicine, General Medicine Clinic

I have worked with many outstanding PA and NP's during the last 30 years and have seen many changes. I enjoy working with a NP partner. In New Mexico, there are many small rural cities where we cannot get physicians to go, in part because there aren't enough. In my small city, we are short 16 primary care doctors. The two cities next to me are both short at least 20 doctors. There are a few small towns lucky enough to have a NP to provide primary care. I AM GLAD THAT THEY CONSULT AND ADMIT LIBERALLY. THEY ARE ISOLATED AND HAVE NO BACKUP OR CONSULTATION. I wish that we could set up a system of consultation or backup doctors to support these rural practitioners, either NP's and MD's. New Mexico needs this system.

Lisa Frey, FNP-C Other Healthcare Professional, Geriatrics

I have been a NP for 20 years. I have no desire to pursue independent practice free of physician oversight. My perfect practice is working in tandem with a MD that is freely available for the occasional times I need a consult. This should be a mutually respectful partnership.....not about anyone's egos. Once MDs and NPs finally become aware the practice of medicine is best performed when the primary goal is patient well-being and not ourselves....then we will finally be on the road to true health care reform.

* * Physician, Internal Medicine, Academic Medicine

I have worked in academic medicine for 10 years. I work directly with medical students, physician assistant (PA) students and nurse practitioner (NP) students. Additionally, I have worked extensively with PA's and NP's who have already completed their academic training.

Comparing a medical student to a PA or NP student is night and day. The knowledge base of a medical student far exceeds that of the NP and PA students. Anyone who works in academics with all 3 of these types of students would agree.

Licensed NP's and PA's who are given the okay to practice medicine without several years of experience in that particular field is a danger to patients. They have a very limited knowledge base upon completion of school and do a sort of on the job training post school with "full licensure." A medical student undergoes further training post school for 3-8 years (depending on specialty) with a "training license" and direct MD supervision. Why are we letting NPs practice medicine without enough training post NP school? I think it's a recipe for disaster. The NP's should be expected to do a 3 year residency just as the medical students do to ensure adequate knowledge base in internal medicine/ family medicine.

Sylvia Ross PhD, CNM Other Healthcare Professional, Obstetrics/Gynecology, Academic Institution

Nurses do not consider themselves "physician extenders". Nursing is a well established professional discipline separate from medicine. Nurses are not physician assistants or extenders, they are an important and valuable members of the healthcare team. Labeling nurses as "physician extenders" is offensive, and should be reserved only for PAs.

Anne Arikian Physician, Family Medicine/General Practice, UCLA

I've worked alongside nurse practitioners my entire medical career, and here is my take: experienced NP's are a valuable addition to many practice types, and have unique qualities and characteristics which can be highly desirable. I have found that an experienced NP is competent to handle much of the breadth of primary care, and knows when to confer with a colleague or seek a consultation for more complex issues.

I think many primary care doctors rely heavily on consultants to manage relatively ordinary chronic care conditions, and NP's are not unique in this regard.

I do feel however that a practicing physician fresh out of residency or fellowship is FAR more qualified than a newly trained NP to handle just about any clinical scenario. The takeaway for me is that I would favor expanded scope of practice for "seasoned" NP's, say with 5 or more years of experience, but not for newbies who just graduated from a 2 year NP program.

pete council, MS,MSEE,MD Physician, Family Medicine/General Practice, private practice

for the chaos and bad outcomes associated with unsupervised NPs check out Northeast Montana

eliz rash PhD ARNP FNP-C NCMP Other Healthcare Professional, Family Medicine/General Practice, cfp

Need reference for inc. admit/hosp but really what we care about is patient outcome. Did the inc. referrals and admits result in decreased morbidity (hence decreased cost) and mortality?

Jerry Garich, PharmD, MS Other Healthcare Professional, Pharmacology/Pharmacy

Finally some coherence and rationality about the unjustified expansion of NP scope of practice. Everyday we in pharmacy see the drug utilization patterns of NPs, MDs and others. We are legally charged to decided if prescribing is safe and effective per accepted guidelines, FDA approved drug due information etc. we often have issues with physicians on these matters. However with the expansion of NP prescribing the appropriate drug use issues have impeded several fold. Most of the drug misadventuring never will go detected however it results in worse patient care and I feel inferior clinical outcomes. It met be addressed!

Bill Wegesser BSN, PA-C Other Healthcare Professional, Pulmonary Medicine, Dept of Hyperbaric Medicine and Wound Care in SLC,UT

There will undoubtedly be pro's and con's to any group providing medicine in our country. By most if not all state law/statutes PA-C's must work under the asupices of a physician. NP's may hang their own shingle but I know of very few that do. I think both groups (NP and PA's) would benefit from some type of guidance, especially if it is not "profit" motivated.

Robert Willis, MD Physician, Pediatrics/Adolescent Medicine, Primary Care , small single specialy

I sincerely believe that nurse practitioners should work under the direct supervision of a physician. Be that as it may, I believe that in a generation, most primary care will be provided by NP/PA. I have had several NP work for me in the past. They were delightful, women, well trained. One had previously been a NICU nurse and and another a PICU nurse. I would still have them because they made money for me, I had less phone calls and less paper work; but my practice was not growing. So when one left, I let the other one go and hire a physician and in spite of lots of competition, my practice is growing steadily. What I noticed was that NP's do not have the basic science fundamentals that we do. We had 2 solid years of nothing but anatomy, physiology, biochemistry, pathology, microbiology. They had one semester of these at a college level. Then we has 2 years of clinical rotations and 3 years of residency for primary care. They had 2 years of clinical work. They are not able to problem solve very well because they do not have the thorough fund of knowledge that physicians do, so they have to ask lots of questions. They may follow an algorithm well, but if there is a kink in the algorithm, it is difficult for them to figure it out on there own. I have seen it, I have lived it. They are good, they spend more time with a patient, but they new good back up. Perhaps we should have Primary Care docs spend 4 years in training like the Canadiens do and then set up practices where you have a physician/leaders and multiple NP/PA under them. That is where I see it going anyways to reduce the shortage of primary care physicians and to decrease the cost of health care.

Paul April Physician, Rheumatology, Retired

Author correct as is the comment about paying certain specialities(including cardiololgy) less in order to pay primary care more.The best trained nurses may be better than a non specialist physician in certain narrow areas but it requires the broad and deep knowledge of a well trained physician for,proper diagnosis and treatmenttreatment in situations where the solutions are not obvious. obvious.
A hallmark of poor quality of physicians as well as NP's is underdiagnosis and overtreatment

Paul April Physician, Rheumatology, Retired

Author correct as is the comment about paying certain specialities(including cardiololgy) less in order to pay primary care more.The best trained nurses may be better than a non specialist physician in certain narrow areas but it requires the broad and deep knowledge of a well trained physician for,proper diagnosis and treatmenttreatment in situations where the solutions are not obvious. obvious.
A hallmark of poor quality of physicians as well as NP's is underdiagnosis and overtreatment

JITENDRA MISHRA MD Physician, Cardiology, AL AHLI HOSPITAL QATAR

EVEN THOUGH DOCTORS PASS THROUGH VERY STRUCTURED PROLONGED TRAINING PROGRAM WITH LOTS OF ASSESSMENT HURDLES , IS IS VERY SURPRISING THEY
BE REPLACED SO CASUALLY WITH NURSES , WITHOUT HARMING PATIENTS AND INCREASING COST OF TREATMENT

kent davenport Physician, Orthopedics

Are the nurses required to have malpractice insurance. What rates will they pay considering their training and responsibilities

Cheryl Campos, PhD, BSN, RN Other Healthcare Professional, Emergency Medicine

The trend to use NPs is there for a reason. The reality is that some NPs perform better than some MDs for various reasons. The roles should not be in conflict with one another and should be cooperative. The trend is here to stay. I hope that with the independence given to NPs there will be increased oversight on the education at that level. Too many NPs get their degrees online with little to no oversight in quality or whom is completing that education. Quality and patient safety should be the motivating factors not dollars.

Matthew Butler, MD

The reason for the change is not because there NPs 'do better' than physicians. It's solely because the government is looking for cost-effective solutions for the primary care shortage

Larry Eninger, MD Physician, Ophthalmology, office
Competing Interests: I'm a physician who believes the trend to treat at the lowest possible level of expertise, is not in the best interests of patients.

It always amazes me how some people are quick to attack someone for presenting facts when those facts contradict what they want to believe.

Richard Henighan, APRN, FNP-C Other Healthcare Professional, Family Medicine/General Practice, Good Shepherd Clinic, Sevierville, TN

I'm a mostly retired Family Nurse Practitioner with 35+ years experience. As your comments imply, the data Dr. Jauhar' offers for his position are totally inadequate, but as the reader comments to the NYT make clear, that's not the main issue here. For me, the issue is removing outmoded legal barriers to practice for qualified, willing providers. Is an NP right out of school qualified for independent practice. No, absolutely not, but neither is a physician right out of medical school. If personal ethics don't ensure the protection of patients in this regard, then the norms of one's profession keep folks in line on these matters. If these fail, that's a job for the State Boards of Nursing or Medicine. .

Adam Kaul Physician, Psychiatry

First, No physician is able to ever practice right after four years of medical school. They must complete an internship, and residency, obtaining another 3 to 7 years of training and experience.

Second, in many states, the NP's and PA's oversight and scope are very politically driven, rather than being beholden to ethics and quality oversight. I have never heard of any NP or PA group requesting full autonomy, but only after a certain number of years' experience (or with any other qualifiers).

I believe that physician extenders certainly can and should have a role in health care. It should, however, be within a supervised setting.

Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
Image CAPTCHA
Enter the characters shown in the image.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.

Advertisement
Advertisement
Advertisement