Why Not A Nurse?

(This Alert was written with Virginia Traweek.)

After Hurricane Katrina hit New Orleans, several hundred thousand refugees descended on Dallas, Houston and other Texas cities. Many of them needed medical care. Unfortunately, Texas wasn’t prepared.

If a natural disaster hit Oregon, the victims would have fared much better. The state’s 8,500 nurse practitioners (NPs) are free to come to the aid of people in need of care, with no legal obstruction. In Oregon, nurses with the proper credentials and licensure may open their practices anywhere they choose and operate in the same capacity as a primary care physician without oversight from any other medical professionals. They can draw blood, prescribe medications, and even admit patients to the hospital.

 In Texas, which has some of the most stringent regulations in the country, however, a nurse practitioner can’t do much of anything without being supervised by a doctor who must:

  • Not oversee more than four nurses at one time.
  • Not oversee nurses located outside of a 75 mile radius.
  • Conduct a random review of 10 percent of the nurses’ patient charts every 10 days.
  • Be on the premises 20 percent of the time.

Why Not Me?

Note that under the rubric of “nurse,” there are a host of subcategories. In general, nurse practitioners have the skills to prescribe, treat and do most things a primary care physician can do. They generally must have completed a Registered Nurse and a Nurse Practitioner Program and have a Masters or PhD degree. In addition, there are physician assistants, registered nurses, licensed vocational nurses, emergency medical technicians, paramedics and army medics. In most states, each of these categories has its own set of restrictions and regulations, delineating what the practitioners can and can’t do.

If all this sounds like the reinvention of the Medieval Guild system, that’s exactly what it is. In Capitalism and Freedom, Milton Friedman argued that these labor market restrictions are no more justified today than they were several centuries ago. The proper role of government, said Friedman, is to certify the skills of various practitioners; then let consumers decide what services to buy from them.

Take JoEllen Wynne. When she lived in Oregon, she had her own practice. As a nurse practitioner, she could draw blood, prescribe medication (including narcotics) and even admit patients to the hospital. She operated like a primary care physician and without any supervision from a doctor. But, JoEllen moved to Texas to be closer to family in 2006. She says, “I would have loved to open a practice here, but due to the restrictions, it is difficult to even volunteer.” She now works as an advocate at the American Academy of Nurse Practitioners.

Texas’ misguided attempt to protect its citizens from people like JoEllen Wynne makes it virtually impossible for nurses to practice outside of a primary care office. Take the requirement that a doctor be present and spend at least 20 percent of her time supervising her nurses. If they are employees of her office, she automatically meets the requirement simply by being on site. Otherwise, she must travel and spend 20 percent of her time out of the office.

Walk-in clinics manned by nurses in pharmacies and shopping malls seem to have overcome these legal barriers. But in poorer areas — especially in poor, rural areas — the obstacles may be insurmountable. In 2009, approximately 30 percent of Texas counties had poverty rates of 20 percent or more. Most of these are rural counties. Yet the farther a nurse is located from a doctor’s office, the less likely the doctor will be to make the drive to supervise the practice. In medically underserved areas, a doctor must visit a nurse practitioner at least once every 10th business day. This means that people living in poverty-stricken counties in Texas must drive long distances in order to get simple prescriptions and uncomplicated diagnoses.

The requirement that a nurse practitioner’s practice must be located within 75 miles of a supervising physician creates another complication: if a doctor supervises independent nurses, she must travel to their locations to supervise them. A physician with four nurses located in rural areas could end up driving hundreds of miles a week, taking valuable time out of her practice to spend reviewing the patient charts.

Another example of the harmful effects of medical practice statutes is provided by the State of California:

After more than 6,600 people overwhelmed volunteers at a free mobile health clinic in Los Angeles last year, California legislators passed a law making it easier for out-of-state medical personnel to assist with future events.

But just over a week before the massive clinic returns, the state has failed to adopt regulations needed for the additional volunteers to participate. As a result, only medical personnel licensed in California will be able to treat patients and some people could be turned away.

Think about that. Doctors from Nevada, Arizona and Oregon can’t even cross state lines and deliver free care to people who need it!

The inability of paramedical personnel to deliver care they are capable of delivering will exacerbate the expected primary care shortages in the coming years. There are 778,000 practicing doctors in the United States. Just under half of them are primary care physicians. Even before health reform, the Association of American Medical Colleges estimated a growing shortage of nearly 131,000 physicians by 2025. The United States will need an additional 65,000 primary care physicians just to keep up with demand.

In a world of rapidly rising health care costs and inadequate access to care, state legislatures should be widening the market for highly-trained primary care providers, not restricting it.

 

 

Comments (70)

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  1. David R. Henderson says:

    John and Virginia,
    Excellent post. See my cross-posting at:
    http://econlog.econlib.org/archives/2011/10/free_the_nurses.html

  2. George Sack says:

    The illogic of the situation in different states is obvious but must remember that malpractice risk is generally affected by the regulations where the practice occurs. Thus, a more uniform set of regulations – likely not imposted for each state – may be needed.

  3. Devon Herrick says:

    Nurse practitioners (MPs) will increasing have a place in the continuum of care. One concern is that NPs are already erecting barriers to entry to their profession. I believe by 2014 most NPs programs will require a doctorate rather than a masters degree.

  4. Keith says:

    NPs are, on the whole, unquestionably less qualified to practice medicine than are MDs/DOs. But that’s not the issue. (After all, even among physicians, there are some who are much less qualified to practice medicine than others.) Instead, what truly matters is whether NPs are capable of delivering “good enough” care.

    Unfortunately, the current health care financing system will not allow the debate to be framed in this way. Whether an NP provides good enough care is irrelevant under an insurance system in which patients are insulated from the cost of their health care choices. (Prices being equal, which patient in his right mind would choose a University of Phoenix-trained NP over a Harvard-trained MD?)

  5. Hank Gardner says:

    YES…BUT. My 40 plus years in heathcare has included partnering with, employing and educating NP’s and YES they provide a valued primary care service that all states would benefit from! BUT our real problem is primary care physicians are not providing primary care because “what get’s paid for get’s done” and our insurance reimbursement model penalizes cognitive primary care. In the absense of market dynamics demand for medical technical services, that do get generously paid for, result in overutilization & cost and a pseudo-shortage of primary care physicians. Hank Gardner, M.D.

  6. Steve Reeder,M.D. says:

    John,
    I recall a few years reading that when some family doctors in rural areas retired, some of the restrictions on NPs would be suspended in an effort to entice them to move to these areas. This was not successful, and the usual reason that an NP gave was that the pay was too low, Medicaid being the primary payor.

  7. Morris Bryant, MD says:

    A great post and I can’t wait to share it with the NP’s and CNM’s I work with, who daily care for 100′s of patients, providing them first class care.

    Please allow me to take a different twist on this issue. The restrictions in Texas would come to an end if the physician community decided to stand up and lead (read: lobby the legislature) for the sake of more and less costly health care for the citizens of Texas. Unfortunately, many MD’s are caught in the same type of protectionism mind set that has so often plagued those fearing loss of market share due to the occurrence of disruptive innovations. While never admitting to this, we instead play the fear game and say that patient care will suffer if it is not provided at the MD level.

    History is replete with examples of greater goods and services being provided in the market place when innovation is allowed to bring about change. A little Schumpeterian creativity is in order, I think.

  8. Anonymous says:

    Due to privacy laws I’m making this post significantly generic.

    My wife, who is a doctor. Recently saw a patient in a hospital somewhere in this country, in a state that does require doctor oversight over midlevels. This patient was a 4 year old child that had been prescribed psychotropic medications with no pediatric indications, in dosages 50% higher than the recommended highest dosage in adults. My wife said this kid could have had a heart attack, and could likely have permanent side effects from these drugs. Whats more, once the drugs were removed, almost all symptoms of any psychiatric problem went away.

    When called, the Nurse Practitioner who prescribed these drugs said, as an excuse “I don’t know what I’m doing.” She also said her sponsoring doctor checks in like once a month. This was a nurse who easily had 20 years of experience as well.

    What is so alarming is not just that the nurse practitioner acted this way, but that she recognized she was in over her head, and she continued in the behavior. Perhaps nurses need to take the oath to “first do no harm” as well, because for any medical professional if you don’t know what you’re doing, and you know you don’t know what you’re doing, then you shouldn’t try anything.

    This nurse knew she was in over her head, but tried to muddle through it anyways. It is like she didn’t even realize prescription drugs could be dangerous if used incorrectly. And again, this is a state that requires a supervising physician.

    This nurse will hopefully lose her license, and the sponsoring doctor will have something to deal with as well. There may even be a criminal investigation. Every patient of this nurse needs to be notified that they may have a dangerous prescription.

    I realize this is an anecdote, but would you really want to trust the care of your child to someone like this? I think this is a pretty compelling reason for “Why not a nurse.”

    Economically using midlevels may make sense, but in the end all it is is a lower standard of care. They are not doctors, they do not have the training of doctors. These are the cheap knockoffs of the medical world. On the surface they may look like a good value, but the quality isn’t there if you look deeper.

    In situations where they work they’re able (and required) to check in hourly with a sponsoring doctor. Ideally they’re in the same building, working together. A midlevel being to a physician what a hygienist is to a dentist. That kind of relationship would work.

    And maybe it would be okay in cases of emergencies, like Katrina.

    But advocating permanent independence of midlevels, giving them all the power of a physician, without the training. That is a disaster waiting to happen.

    It could be our economy needs multiple tiers of healthcare quality. Maybe if you had government insurance you’d be stuck with a midlevel, with better private insurance getting you doctor access. Maybe that is all we can afford. But you need to tacitly acknowledge that midlevels aren’t the real thing.

  9. politicaldoc says:

    How many of the commentors on this post have received care on a continuing basis from a nurse practitioner?

    It is well known that RN’s routinely refuse care from NP’s and insist on seeing a physician.

    Anonymous’s story of poor care and particularly the arrogant attitude of NP’s toward doctors and patients is not uncommon–many physicians have had similar interactions with NP’s.

  10. Frank Timmins says:

    @politicaldoc

    As J. Goodman suggests, those RNs or docs (or anyone else) would not not “required” to use NPs. If they turn out to be less than competent, they will not be successful. It sounds like an excellent opportunity to take the pressure off the primary care physician crunch (as someone suggested previously). It would seem that NPs would be infinitely qualified to handle the multitude of visits for respiratory issues, sprains and scrapes, and all those routine services that most MDs are probably overqualified to be handling.

    I wonder what role the TMA has in keeping the status quo or trying to liberalize the current laws in this regard?

  11. Tom says:

    Good points, John.

  12. David Williams says:

    If nps are so dangerous I wonder why such doctors like Larry Kaiser head of the Temple Medical School and health research organizations like the Institute of Medicine support nurse practitioners working without physician supervision and delegation?

    My entire family uses an NP for routine care, ie. primary care. The folks that gave us Obamacare (the AMA) fight us every step of the way. Not too long ago only a physician could pierce ears. Now, you can go to just about any retail store and get it done.

    Docs used to prescribe smoking to ease anxiety. Ooppps.

    Seems like docs are slow to change and are not always right.
    So, anonymous and politicaldoc………….take your blather elsewhere.

  13. Buster says:

    I wonder if there is any resentment between NPs and nurses (RNs/LVNs)? I’ve also heard the claim that “nurses will not use a nurse practitioner.” I have no idea whether it’s true or not. I would like to patronize a practice design where I have a choice of NPs and MDs/Dos depending on what’s wrong with me. I know nurse practitioners whose medical expertise I trust.

  14. politicaldoc says:

    Counterpoint:

    http://www.tafp.org/advocacy/resources/PCCIssueBriefScopeCost.pdf

    “Contrary to the claims of nurse practitioner organizations, independent practice by nurse
    practitioners would not lead to more efficient or cost-effective care; in fact, studies show the
    opposite would be the likely outcome.
    Because they lack the training and medical education of physicians, nurse practitioners tend to refer
    patients to specialists and order expensive diagnostic tests at a higher rate when they are not working
    with physicians.”

  15. Teresa says:

    I wonder if there is any truth to the fact that people are tired of the long wait times to get in to see a doctor. I also wonder if they are tired of the excessive costs.

    Is it true that people would rather see a nurse practitioner than a physician?

    I have heard that is true.

  16. Buster says:

    A few years ago research found high satisfaction among people who went to a NP because the NP seemed less in a rush and listened more. It would be interesting to see if this is still the case.

  17. Allyson says:

    Buster

    Here are just a few of the 40 years worth of peer reviewed articles for your education.

    Studies of Effectiveness of Advanced Practice Registered Nurses
    Brown, S.A. & Grimes, D.E. (1995). A meta-analysis of nurse practitioners and nurse midwives in primary care. Nursing Research, 44(6), 332-339.
    Fairman, J.A., Rowe, J.W., Hassmiller, S., &Shalala, D.E. (2011). Broadening the scope of nursing practice. The New England Journal of Medicine, 364: 193-196.
    Hogan, P.F., Siefert, R.F., Moore, C.S., & Simonson, B.E. (2010). Cost effectiveness analysis of anesthesia providers. Nursing Economic$, 28(3), 159-169.
    Horrocks, S., Anderson, Elizabeth, & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324: 819-823.
    Laurent, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2009). Substitution of doctors by nurses in primary care (Review). The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 1. http://www.thecochranelibrary.com
    Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., Lin, S.X. (2004). Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Medical Care Research and Review, 61(3), 332-351.
    Mendenhall, R.C., Repicky, P.A., & Neville, R.E. (1980). Assessing the utilization and productivity of nurse practitioners and physician’s assistants: Methodology and findings on productivity. Medical Care, XVIII(6), 609-623.
    Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W., Cleary, P.D., et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians. Journal of American Medical Association, 283(1), 59-68.
    Naylor, M.D. & Kurtzman, E.T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-899.
    Salkever, D.S., Skinner, E.A., Steinwachs, D.M., & Katz, H. (1982). Episode-based efficiency comparisons for physicians and nurse practitioners. Medical Care, 20(2), 143-153.
    Sandall, H.M., Devane, D., Soltani, H., Gates, S. (2009). Midwife-led versus other models of care for childbearing women (Review). The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 3. http://www.thecochranelibrary.com
    Sekscenski, E.S., Sansom, S., Bazell, C., Salmon, M.E., & Mullan, Fitzhugh. (1994). State practice environments and the supply of physician assistants, nurse practitioners, and certified nurse-midwives. The New England Journal of Medicine, 331(19), 1266-1271.
    Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, R.S., Gent, M., Kergin, D.J., et al. (1974). The Burlington randomized trial of the nurse practitioner. The New England Journal of Medicine, 290(5), 251-256.
    U.S. Congress, Office of Technology Assessment. (1986). Nurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis (Health Technology Case Study 37). Washington, DC: U.S. Government Printing Office.

  18. Norma says:

    Hey Politicaldoc…..
    I read the article you provided as well as the Hermani reference used to back up your claim. This sure seems like a dubious piece you have provided.

    I read the Hemani article that is referenced and quoted on p. 5 in which states that utilization was higher among nurse practitioners in “14 of 17 utilization measures compared to residents and 10 of 17 measures compared to physicians.”

    The original article by Hemani states that only 3 of these measures were statistically significant. (Comparing residents to attending physicians, 2 were significantly different). The author refers to the findings as a “trend” and states “but for most of these our study lacked sufficient power to show statistical significance”.

    Furthermore, the author acknowledges it was not possible to know who ordered a radiographic study- whether specialist or primary care provider.

    This is another trick the doctors use. They create these research pieces that are multi-colored and seem to be factual……….until you look at the details in the research they quote.

    Here in Texas, a nonpartisan legislative agency actually took the “research” provided by the Texas Academy of Family Physicians and noted the faulty claims.
    It was quite hilarious and shows folks just how far the physician organizations will go to protect what they believe is turf and nurses believe are patients.

  19. Linda Gorman says:

    More to the point, why license medical practitioners at all if there aren’t any quality differences, as seems to be the contention in a number of these comments?

  20. Jay Gregory says:

    John: If any individual wants to practice medicine, they should go to medical school, not go to nursing school and call themselves doctors. There is nothing wrong with a nurse seeing a patient, but the patients most often come to believe that the nurse can do anything a physician can do. Not so!! If you want to practice medicine, go to medical school. JGregory

  21. Bob Deuell says:

    Dear Mr. Goodman:

    Your recent “Health Alert” regarding practice by advanced nurse practitioners does not represent the situation accurately or fairly.

    First, let me state that I have the highest respect for advanced nurse practitioners. As a family physician, I have worked with ANPs for 30 years and I hired the first ANP in Hunt County 24 years ago. In addition, I have served as a preceptor for ANP students and my medical practice in Greenville employs both nurse practitioners and physician assistants and they practice to the full extent of their education and training. Current Texas law does not prevent that.

    Despite our admiration for nurse practitioners, most physicians oppose independent practice because their level of education and training does not qualify them to practice without physician supervision. ANPs are a vital part of our health care system, but their profession was never intended for independent practice.

    Board certified family physicians have a four-year bachelor’s degree; four years of medical school; and then at least three years of advanced and intense clinical training called a residency. Most ANPs have a four-year degree in nursing and a master’s degree. Comparing training hours, a family physician has 15,350 – 18,900 more hours of training than even an ANP with a doctorate degree.

    There is no evidence to support that an expanded scope of practice for ANPs will increase access. In states that allow this, the demographic maps do not show an increase in the number of ANPs going to more underserved areas.

    Studies also show that ANPs in independent practice refer more to physicians consultants by 25 percent, and there is a 41 percent increase in the hospitalization rate for patients under the care of independent ANPs. This increases the cost of health care.

    Texas patients would be better served to leave the current law regarding advanced nurse practitioners as is.

    Thank you for your time. If you have any questions or would like to discuss this further, please don’t hesitate to contact me.

    Sincerely,

    Bob Deuell, M.D.
    State Senate, District Two

  22. Marti Settle says:

    Dear John,

    Very good. However, I know several practicing NP’s right here in North Texas. The doctors DO NOT come to see them every 10 days. They do not audit patient charts as the law stipulates. I do not know which doctors oversee more than 4 NP’s at a time but these laws are NOT enforced. Texas is great at making stupid regulations but does not pay for enforcement. The only way a NP would be checked is to receive a complaint from a patient. Otherwise, these audits and oversights are a laughing stock. The people at TDHS write these silly, draconian regulations and laughingly call them “job security.” I personally have had one tell me that the silliness of laws regulating my industry are job security for her. Austin is full of liberal job hugging transplants who know how to write dumb regulations to ensure their jobs under the guise of public safety. Been there, seen it. Documented it.

    Warm regards and Go Rangers

  23. Howard says:

    Dr. Deuell uses a standard tactic used by the medical associations. He throws data at you that is false and shows nothing to back up the claim.

    In states with both a favorable regulatory environment and large percentage of rural residents, NPs are significantly more likely to practice in rural settings.

    According to the Journal of the American Medical Association, 9% of primary care providers practice in rural settings while 23% of advanced practice nurses move to those same areas.

    In Dr. Deuell’s home state of Texas, there are currently 11 counties without a physician but you will find a practicing APRN.

    It is true that NP education is different from physician education, although such difference is not evidence that one model is superior to the other. As mentioned previously, there is consistent evidence that the clinicians prepared through NP educational programs demonstrate high quality care, with excellent outcomes, indicating that they are well-prepared for the role they take on, once graduated. Programs are designed with a population focus, allowing NPs to develop the knowledge and skills relevant to the population they choose. NP education is competency-based, rather than relying on clock-hours spent in rotations. This means that students do not progress until they have achieved and demonstrated competencies at each level of their program. One unique aspect of NP education is that students enter these programs with an average of 10 years of professional nursing experience.

    Patients need care and the physicians are more than happy to continue to limit access and options. It is sad.

  24. Anonymous says:

    @david williams

    My comment was not “blather.” It is a factual, accurate, account of something that happened last week. You might want to call it anecdotal, and you’d be right, but it isn’t blather.

    I was shocked, I had no idea NPs could prescribe medications, I thought they could ask their sponsoring physician to prescribe something, or recommend it, but I had no idea they had the power to do so themselves. Would you also support such power for psychologists? How about chiropractors? Both groups have tried to get it (and may already have it in some states).

    In my opinion the relationship that works is one where the midlevel and the physician are in the same practice in the same building with a relationship similar to a resident and an attending at a teaching hospital. The midlevel works up the patient, then presents it to the physician, saving the physician time, but maintaining a strict level of oversight.

    Look at my example though, you think this family saved money by going to an NP? The NP which prescribed drugs off label, for misdiagnosed psychiatric problems, in dosages 50% higher than the maximum recommended, for adults with severe psychiatric problems, on a 4 year old. It wasn’t just one drug, it was a whole cocktail. So now the kid has a long stay in a hospital, god knows how many tests, and potentially long term side effects. What is the cost of all that?

    What is the cost of missing a cancer diagnosis? What is the cost of an inaccurate diagnosis of anything? The primary care physician is there to treat small, minor, or common problems, but also to recognize things that may be more serious. I have no doubt that an NP could adequately treat a patient where you know what is wrong with them is something minor. I have serious doubts about their ability to diagnose an unknown problem, or to recognize symptoms of a more serious disease when they present themselves. Sometimes heartburn is really esophageal cancer.

    This in the end is all about hubris and pride. Professional hubris. I have a problem with chiropractors too. If they stick to treating back pain, okay, they can have some success. But as a profession they only have one tool in their toolkit, and they try to apply it to more situations that it is applicable for. I have seen some claim things are far out as spinal manipulation replaces a need for vaccination in babies. These people are nuts, and yet patients will go see them, and believe them, not realizing they’re not real doctors because they’ve managed to lobby the government for recognition of some sort.

    NPs probably know more about medicine than chiropractors, but they’re not real doctors either. Putting them in a position where they’re expected to perform all the duties of a primary care physician is a bad idea, and the ones who think they can do everything, like the lady in my example, suffer from the same hubris as some chiropractors.

    People might claim that doctors just want to maintain their ability to make money, they don’t want the competition. That is ridiculous. I have never met a doctor (and I know many) who has problems finding patients. I know more doctors who are taking no new patients than who need patients.

    But money is a factor. You think an organization representing NPs and PAs aren’t funding studies and lobbying state governments all over the country for these additional powers (without any additional education) so that they can bill at a higher level, or make more because they don’t have to pay for physician oversight?

    You have people with significantly less education, and also probably less intelligence (considering the relative difficulties in school admissions), insisting they can do the same job as a fully trained physician. Hubris.

  25. Anonymous Too says:

    Well, my grandfather had a physician that almost let him die because he diagnosed the spot on my grandfather’s nose as a scab and not skin cancer. After the 3rd visit to that doc to discuss why the spot was getting larger, the receptionist told my grandfather as he was checking out that he needed to get a second opinion cause it looked like skin cancer to her.

    Immediately upon walking in to the next doctor’s office, the RN looked at him and said “we need to get you to a specialist NOW.”

    While in surgery the surgeon steps out to tell us it may have spread too far but they would do all they could to save him and most of his facial features.

    Luckily, he just lost his nose. Thanks to an RN, my grandfather lived another 20 years. I wonder how much that doctor increased costs to my family? So forgive me if I have some trust for nurses, especially nurses with advanced practice degrees.

    When humans are providing care, no matter their education or specialty level, there will be mistakes. If we are going to limit the ability of an medical professional to practice to the level of their education and certification, then we best get to limiting physicians too.

  26. Al says:

    Just a few quick considerations:

    _NP malpractice costs will rise as their risks rise.
    _MD malpractice costs will rise as well as they would be managing a higher percentage of more serious problems.
    _Shifted professional costs. If one group manages less serious problems the other group will have to charge more.
    _Productivity differences
    _Salary differences and how large are they?
    _Greater reliance upon sub specialists with less trained personal. That leads to higher costs.
    _Added liability to sub specialists with less trained primary care personal.
    _Long term results.
    _Insurance quagmires.
    _Quality concerns with sudden increase in NP numbers.
    _Overall quality concerns since physicians have already been accused of lack of quality. How does reducing the amount of education required improve quality?
    _Are we dummying down the system?
    _Why do we need medical school?
    _Why should we license at all?

  27. Uwe Reinhardt says:

    I would be inclined to say that I fully agree with John on this one, were it not for the fact that, if it was ever leaked that John and I agreed on something, we would instantly lose all our respective friends, including Don McCanne.

    The fact, though, is that I have harped on the same theme, in the same manner, for over three decades now, influenced in good part by Milton Friedman’s classic little book CAPITALISM AND FREEDOM. Additionally, my attitude on this one probably can be traced to the fact that my mother used a midwive rather than a doctor when I was born and, as everyone I hope would agree, I am living proof that midwives can produces truly superb babies.

    I recall serving on an Institiute of Medicine study panel on dental care just as President Reagan had ascended to the White House. A certain HANES study had found a huge unmet need for basic dental care among poor American children. Quite innocently, as a young punk economist, I proposed that, in the face of a shortage of dentist, we should let dental nurse practitioners on the New Zealand model do straightforward drilling and filling, in their own practice. A blind study in Canada which I cited had shown that on average well trained dental nurses actually did a better job (on school-age children) in simple drilling and filling than did dentists. My plea fell on deaf ears, whereupon I wrote a 30 page minority report that, alas, did not make its way into our study panel’s final report. I must have stepped on someone’s toes, I reckon. But I still have that minority report somewhere.

    Dean Mary Mundinger of Columbia University’s School of Nursing actually has set up independent NP practices in NYC, much to the chagrin of NYs Medical Association.So it can be done — alas not in New Jersey, nor in Texas, the legislatures of which had voted not to enter the 21st century in medical matters, nor even the second half of the 20th.

    One does not have to be a cynical economist to smell a rat upon realizing that most professional licensing laws are composed and legislated at the behest of the professionals themselves, rather than their customers. Paul Feldstein used to have a whole chapter on that in his text on health economics.

    I also remember the huge and amusing fight over the question whether opticians should ever be allowed to dilate pupils.

    Anecdotes on poor quality of NP care on this blog do not persuade me. There are plenty of anecdotes of poor care among physicians as well.

    So, I cheer you on, comrade John, in this march for professional freedom. In the end we will win this fight.

    Best,

    Uwe

  28. David Williams says:

    Anonymous

    I apologize for the insensitive comment. You do deserve better care but poor care is provided sometimes up and down the professional spectrum. The fact is that nurse practitioners were created to help ease the shortfall of primary care providers. The position was created by a physician and a nurse working together for the good of patients. NPs provide high-quality care but there are some instances where mistakes are made or a bad apple slips through the cracks. The same happens with physicians.

    Again, I am sorry bit the one bad experience you had is not representative of the entire profession.

  29. Morris Bryant, MD says:

    At Marti, et al: Referring to my original post: Physician leadership MUST LEADS as regards NP’s – if they hire them then they must supervise and follow the law. Failure to supervise is a physician failing. NB: I do not endorse fully independent practice of ANP’s except in critical situations / needs. There must be a clear line of supervision that does protect patient care quality and provide the safety net for complex problems that require complex training. Boiled down: midlevel providers should be trained to perform specific tasks and monitored to assure that scope of practice does not exceed training.

    At Dr. Deuell: No there probably aren’t any studies to back that specific hypothesis. However economic evidence abounds that more scarce goods or services will be purchased when available and supplied at a lower price. In that arena, the consumer should have more choice. The law AND physicians should work and lead to ensure quality while enhancing access.

    At Uwe Reinhardt: I didn’t think I was ever going to get on the same bus with you. Thank you for your post.

  30. Devon Herrick says:

    It’s interesting that Uwe mentions dental nurses (I think they’re called dental technicians in Alaska, where they’re allowed a limited scope of independent practice). Last summer I was at a conference that brought together trade associations, policy analysts and legislators. I visited the booth of the Academy of General Dentistry. Their representative explained they had two primary policy initiatives: 1) To prevent specialty dentists from carving out areas of specialty practice and reducing community dentists scope of practice; 2) To keep mid-level dental technicians from encroaching on the turf of general dentists and practicing in any form other than working for a dentist.

  31. politicaldoc says:

    So, using the combined health economic wisdom of Goodman & Reinhardt, who both appear empowered by the wisdom of the great Milton Friedman, I would conclude that in most instances the care provided by nurse practitioners is in general just as good as that provided by most primary care physicians. Because there is a need to provide health care to the masses, one cannot quibble about any provider’s credentials because the “greater good” is paramount. The indigent just can’t expect to get the same healthcare as our leaders in Washington DC.

    Why would anyone go through the time and expense of medical school and residency to become a primary care physician only to be told his/her expertise is equal to a nurse practitioner?

  32. Frank Timmins says:

    @ Politcaldoc

    “Why would anyone go through the time and expense of medical school and residency to become a primary care physician only to be told his/her expertise is equal to a nurse practitioner?”

    I was reading over the posts and could not find anyone suggesting that an NP had the same qualifications and expertise as a practicing physician. It seems rather that point of all this is that we might be better off not using all the professional schooling and residency experience to give flu shots, prescribe for sore throats and give tetanus shots. If there is truly a shortage of PCPs would this not be an appropriate response from the medical community?

  33. Sharon says:

    I wonder if any of the docs would be willing to “supervise” a nurse practitioner if they were not getting paid to do so? Is safety only a concern when dollars are at stake or all the time? If it is all the time, then I am wondering if politicaldoc and his folks would all agree to supervise free of charge……..or maybe for a nominal $500 per month and not the thousands they currently charge to review a random 10% of patient charts.

    Politicaldoc, can you comment on this?

  34. politicaldoc says:

    Frank,
    One can quibble over the term “expertise”, but I do believe the main argument begun by Dr. Goodman is that NP’s should be able to hang a shingle and practice independently in Texas. No added value is given to having a medical degree. The argument is to just let NP’s practice medicine without any supervision, which most Texas physicians think is practicing medicine without a license.

    Nurse practitioners feel they should be paid the same as doctors and many feel they have the same expertise as primary care physicians.

  35. politicaldoc says:

    Sharon,
    I think the way you stated things is backward. A NP should not be looking for a doctor to supervise her—rather the physician should be evaluating the NP as he would any employee. The doctor takes 100% responsibility for the actions of any mid-level he supervises.

    I do know of NP’s who simply pay a doctor to be their stated supervisor and then the doctor does no supervision. This is not only unethical but illegal in Texas and should be reported to the Texas Medical and Nursing Boards.

  36. Sharon says:

    Actually, for any NP who owns their own clinic in Texas is required to find a supervising physician. The physician is then required to be onsite 1 out of ever 10 days and to do a retrospective review of a random 10% of charts.

    Is this what you call supervision?

    A physician is only liable for the actions of an NP if the physician knowingly hires an incompetent provider.

    And to the thought that supervision is necessary to guarantee that an NP stays within their scope of practice I am wondering who exactly is supervising family practice physicians? Maybe the internists? Who is supervising the internists? The list goes on.

  37. politicaldoc says:

    Sharon,
    A physician supervisor is always going to be sued for the malpractice of a NP whom he supervises in any capacity. Lawyers aren’t stupid enough to just sue the NP.

    A physician in TEXAS is liable for ALL actions of all mid-levels he supervises. Are you in Texas or another state? Have you ever seen a doctor’s malpractice policy from the insurance company?

    Your snarky last paragraph reveals your true feelings toward primary care doctors.

  38. Harold says:

    Snarky paragraph?
    Sounds like a legitimate question to me.

    Politicaldoc seems to think that an NP program wouldn’t teach an NP to refer on when something falls outside of his/her scope. On one hand you say they refer too much. On the other you say they don’t know when to refer.

    Which is it?

    And, since there is obviously a pecking order in provider types, is it not a valid question to ask who all should be supervised? The specialists sure do fight expansion when family docs believe they can handle certain procedures.

  39. Bob Deuell, M.D. says:

    To Howard,

    I have the data on referrals and hospitalization and the maps for the states that have independent practice. You are using the standard tactic of ignoring facts and data and merely claiming them to be false. Am I wrong on the hours and years of training? When I return home in a few days I will submit the studies.

  40. Uwe Reinhardt says:

    Response to politicaldoc, Oct. 18:

    John and I are not arguing that NPs have the same training and range of professional competence as do physicians. That would be patently absurd. GPs do not have the same training as neurosurgeons or OB/Gyns either.

    But we are economists, and as such we always compare some baseline policy — the status quo — against a new policy.

    The baseline is that many people just cannot afford to see MDs for less severe illnesses or simply can’t access one for other reasons (e.g., rural areas).

    The alternative we are espousing is to allow NPs to hang up a shingle that says NP, not MD. Friedman would make it illegal for an NP to hang up a shignle with MD on it.

    So the choice we see — especially for poor or rural patients — is either no care (but theoretically only from an MD) or some relief, albeit from an NP.

    After all, we send NPs out into the field with our combat platoons, not MDs. Ditto for ambulances.

    There is no reason why NPs should not be electronically connected to MDs at a medical center or in a clinic, but they is also no reason why they should be made economically subservient to MDs.

    They should be allowed to compete with doctors, within the more limited scope of practice for which they are trained.

  41. David R. Henderson says:

    Uwe Reinhardt,
    Well stated. In fact, so well stated that I blogged about your comments here:
    http://econlog.econlib.org/archives/2011/10/uwe_reinhardt_n.html

  42. Frank Timmins says:

    @ Uwe Reinhardt

    Could this be a seminal moment in the quest for triumph of logic over ideology?

  43. John R. Graham says:

    I think one of the problems with the literature (as so often happens) is that scholars who are seldom in the real world believe that, if a regulation states something must be done, then it is actually done in the regulated way. As many commenters have noted, the TX regulations on supervision of NPs are observed “in the breach.” This fact makes any scholarly research on the effectiveness of regulations very sketchy.

    The solution is not to have a bunch of commenters to debate it in a blog, but for the law to ensure that nobody misrepresents himself. After that, let a thousand flowers bloom, with price transparency for all!

    For example, imagine two billboards: “Come to the Lower Slobovian Medical Clinic For Your Primary-Care Needs. You Will Always Be Seen By An MD!”, and another one across the street: “Affordable Care Available at the Upper Slobovian Medical Clinic. We Keep Costs Down By Using NPs!”

    The patients will decide for themselves. Only when government interferes does this become an “all or nothing” decision.

  44. Buster says:

    I agree with Frank Timmins and Professor Reinhardt that no one is saying NPs are as skilled or as highly trained as physicians. I do not believe skill is the relevant issue here. The issue as I see it: is NPs’ lower level of training reason enough to protect patients of the right to make their own choice? Likewise, is MDs’/DOs’ more extensive training sufficient reason to grant them an exclusive license to practice medicine — forcing all other medical professionals to work for them or under their supervision?

    I would argue people should be allowed to make a choice: some people want a specialist for every medical problem (makes sense; why not get the most knowledgeable expert possible); other people want to see the same family doctor who can refer them to a specialist if need be; some people may only want to see a NP that works for a physician practice under the supervision of a MD; while other people may feel perfectly secure to see an independent NP.

    I don’t think it’s safe to say “no added value is given to having a medical degree.” That’s up to patients to decide. I imagine most patients would probably rather see an MD than a NP. But the ability to see an NP afterhours or on weekends might impact their preference. If an appointment with an NP is available that day (rather than a week out) may make a difference. If the condition is minor or the price for a NP visit is lower could also be a consideration.

  45. politicaldoc says:

    Disregarding for the moment that NP’s may be a valid option if no physician is available (e.g. rural Texas), it is overly simplistic to believe that every potential patient can decide whether his symptoms are minor, just requiring a NP, or if that chest pain is serious which might require a doctor. People have died after flu shots and tetanus injections. Medicine is not always “cookbook.”

    Obviously, highly intelligent people such as Drs. Reinhardt & Goodman would choose the “added value” of seeing a physician for any medical symptoms they might have.

    However, when a NP is allowed to hang a shingle, set up an office with no physician on site and it is advertised that the NP can manage most medical problems including chronic diabetes, hypertension, etc., even smart consumers won’t necessarily understand the added value of seeing a physician. Review of 10% of charts days after the visit is not great medical care for the patient who dies of a heart attack because he just did not give the classic textbook pain description to a NP.

    The problem with independent NP’s (because of less training than physicians) is they don’t know what they don’t know. A good physician always considers the worst scenario and does not just treat symptoms.

  46. Harold says:

    Politicaldoc

    I guess that the Institute of Medicine, Dr. Larry Kaiser, Dr. Ken Shine, Dr. Ben Raimer, Dr. Hal Scherz, and Dr. Jeff Sussman (Editor in Chief of the Journal of Family Practice) don’t know what they are talking about when they argue that nurse practitioners should be able to practice to the full extent of their education and training and free of physician supervision?

    So, if these doctors and many like them are wrong, does that mean we should avoid going to them for care? In the case of Dr. Kaiser, he is actually the head of the Temple Medical School and teaching physicians. Will the Texas Medical Association attempt to get him thrown out of his job for fear that he does NOT know what he is talking about?

    You guys only want the current regulations to remain because you want the money, not because nurse practitioners are not capable of providing care. Admit the truth. At least then folks can respect you.

  47. Jeffrey Sussman MD says:

    It’s time to collaborate— not compete—with NPs

    It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ulti- mately unsustainable struggle with advanced practice nurses (APNs). I urge my fel- low family physicians to accept—actually, to embrace—a full partnership with APNs.

    Why do I call for such a fundamental change in policy? First, because it’s the reality.

    In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor fur- ther erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:
    • Nurses should practice to the full extent of their education and training.
    • Nurses should achieve higher levels of education and training through an im-
    proved education system that promotes seamless academic progression.
    • Nurses should be full partners, with physicians and other health care profes-
    sionals, in redesigning health care in the United States.

    Second, I believe our arguments against such a shift in policy don’t hold up.

    Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—prac- tice within the bounds of their experience and training.

    EDITOR-IN-CHIEF
    JEFFREY L. SUSMAN, MD
    Northeastern Ohio Universities College of Medicine, Rootstown
    ASSOCIATE EDITORS
    BERNARD EWIGMAN, MD, MSPH
    University of Chicago Pritzker School of Medicine
    JOHN HICKNER, MD, MSc
    Cleveland Clinic Medicine Institute
    JOHN SAULTZ, MD
    Oregon Health and Science University, Portland (Clinical Inquiries)
    RICHARD P. USATINE, MD
    University of Texas Health Sciences Center at San Antonio (Photo Rounds)
    ASSISTANT EDITORS
    DOUG CAMPOS-OUTCALT, MD, MPA
    University of Arizona, Phoenix
    GARY N. FOX, MD
    St. Vincent Mercy Medical Center, Toledo, Ohio
    RICK GUTHMANN, MD, MPH
    University of Illinois, Chicago
    KEITH B. HOLTEN, MD
    University of Cincinnati
    GARY KELSBERG, MD, FAAFP
    University of Washington, Renton
    AUDREY PAULMAN, MD, MMM
    University of Nebraska College of Medicine, Omaha
    PAUL M. PAULMAN, MD
    University of Nebraska College of Medicine, Omaha
    RICK RICER, MD
    University of Cincinnati
    E. CHRIS VINCENT, MD
    University of Washington, Seattle
    EDITORIAL BOARD
    FREDERICK CHEN, MD, MPH
    University of Washington, Seattle
    LARRY CULPEPPER, MD, MPH
    Boston University Medical Center, Boston, Mass
    JOHN W. ELY, MD, MSPH
    University of Iowa College of Medicine, Iowa City
    LINDA FRENCH, MD
    University of Toledo, Toledo, Ohio
    THEODORE G. GANIATS, MD
    University of California–San Diego, La Jolla, Calif
    CARYL J. HEATON, DO
    University of Medicine and Dentistry of New Jersey, Newark
    FRED MISER, MD, MA
    The Ohio State University, Columbus
    KEVIN PETERSON, MD, MPH
    University of Minnesota, St. Paul
    GOUTHAM RAO, MD, MPA
    University of Pittsburgh
    KENDRA SCHWARTZ, MD, MSPH
    Wayne State University, Detroit, Mich
    DOUGLAS R. SMUCKER, MD, MPH
    University of Cincinnati
    DIRECT EDITORIAL INFORMATION AND INQUIRIES TO:
    EDITORIAL OFFICE
    Northeastern Ohio Universities College of Medicine 4209 State Route 44 PO Box 95
    Rootstown, OH 44272 Telephone: (330) 325-6254
    PUBLISHING OFFICES
    Quadrant HealthCom, Inc. 7 Century Drive, Suite 302 Parsippany, NJ 07054 Telephone: (973) 206-3434 Fax: (973) 206-9378
    Arguments FPs make against APNs sound like specialists’ arguments against us.
    Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ ar- guments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitio- ners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care.
    Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.
    Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition.
    As we ring in the new year, let’s stop clinging to the past—and redirect our ener- gies toward envisioning the future of health care.
    jfp@neoucom.edu

  48. politicaldoc says:

    Harold, those doctors obsessed with making money would surely not waste their time posting on this blog. I don’t think very many Texas doctors are worried about competition from NP’s.

    Could someone please state whether there is any difference between a nurse practitioner and an advanced practice nurse? Also, what is the usual training—does every NP start as an RN? Is there re-certification testing every 10 years (as is for family practice and internal med physicians)?

  49. Harold says:

    Politicaldoc

    There is a difference between nurse practitioners and APRNs. An APRN is any nurse with advanced training……midwives, CRNAs, CNSs. Nurse practitioners on average have been RNs for 10 plus years. They have at least a masters degree and are nationally certified and required to stay current and re-certified. Every program here in Texas requires a minimum of 2-3 years as an RN before acceptance to a masters level program. There could be some instances where that is not the case but each NP is required to have a BS in Nursing before moving to a higher level degree.

    Nurse Practitioners are different than the other APRNs in that over 80% are educated as primary health care providers and move into that field. Since we have such a shortage of primary care physicians and the numbers don’t look to improve, we need a better regulatory structure to fully deploy these assets throughout Texas. Site based and mileage restrictions prohibit the use of these fully qualified providers.

    Now, that does not mean there shouldn’t be a collaborative agreement but the current supervision requirements makes it almost cost prohibitive for an NP to open their own clinic. It is certainly their largest expense ranging well into the thousands each month.

  50. politicaldoc says:

    Thank you, Harold

    Just to be clear, an RN needs just 2 additional years of training to earn the NP designation which is a Master’s Degree?

    I realize that many NP’s have practiced as RN’s for several years before completing an NP program.

    I know 3 RN’s that chose to get their MD (7 years additional training at least). All said there is a significant difference in type of training/ medical thinking/attitude in doing nursing versus practicing as a doctor. But they said their. experience as RN’s made them even better doctors. I know this is just anecdotal.

  51. Harold says:

    All APRN education programs are housed within nationally accredited graduate programs and are accredited by a nursing accrediting organization recognized by the U.S. Department of Education and/or the Council for Higher Education Accreditation.

    The curriculum at all APRN schools includes graduate level content in advanced assessment, pathophysiology and pharmacotherapeutics that build on the content learned in the undergraduate nursing education programs (which includes Anatomy and Physiology). Content also includes preparation to practice in the APRN role (e.g., nurse practitioner) and includes content appropriate for formulation of differential diagnoses and determination of appropriate pharmacologic and non-pharmacologic management of patients for a particular patient population (e.g. pediatrics).

    All APRNs practicing in a given role and population must pass the same licensure exam.

    Additionally, not all physicians in the United States, or in Texas, have been through the same education, coursework or exams.

    According to the American Medical Association, in 2007, 141,000 practicing physicians in the United States were educated and trained in another country, under different educational curriculum and standards. About 60 percent of these practiced in Family Practice and Internal Medicine.

    In Texas, about 13,250 physicians (about 24 percent of the physician workforce) were educated by an international medical school.

    Lastly, there seems to be a move afoot to shorten medical schools for students choosing primary care as their focus. Look at Texas Tech as an example. Medical schools are looking more at the NP model to help get physicians in and out more quickly and to limit debt to the student considering they have chosen a less lucrative field.

    And besides, with all the data and peer-reviewed research available showing the positive outcomes for nurse practitioners, why do physicians want to stand in the way of patients receiving care?

    We have seen the AMA and TMA recommend to their family practice docs the best ways to increase their income. In their recommendations they said hire APRNs which will increase your income and allow you more time away from the office.

    Perhaps money is the real reason physicians refuse to work with their nurse colleagues to find realistic solutions to the access to care shortfall.

  52. politicaldoc says:

    Dr. Sussman et al,

    With the title “The Future of Nursing, Leading Change”, it would seem there is a definite bias in favor of nurse practitioners. Specifically, it is clearly stated in the Obamacare legislation that the US must increase the use of mid-levels to keep down the burgeoning costs of Obamacare.

    http://iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

    I respect differing opinions and mean no disrespect, but didn’t the Obama administration fund this IOM report? Please correct me if I am wrong. I have not yet read through it, but do you know how many non-academic practicing physicians had input?

  53. Harold says:

    The Robert Woods Johnson funded the project. The American Medical Association endorsed Obama Care so what does that say about the AMA?

  54. politicaldoc says:

    Harold,
    You did not answer my question so I will assume an NP is a Master’s level degree which requires 2 years of training post RN/BS in Nursing. Correct me if that is not accurate.

    The TMA & Texas physicians have no objection to the hiring of NP’s who will be supervised; the main argument started by Dr. Goodman is that NP’s should be able to practice independently without any supervision. Most Texas physicians believe NP’s are valuable, but should be supervised by physicians. I await any other input from Dr. Buell.

  55. politicaldoc says:

    The AMA represents about 17% of US physicians. Thousands of doctors dropped their membership in disgust with the AMA’s backing of Obamacare.

    So more power to you to bash the AMA all you want. It does not represent the thinking of the vast majority of Texas physicians.

  56. David Williams says:

    So, now there is a difference between non-academic physicians and physician professors?

  57. David Williams says:

    Politicaldoc

    You are right…….a masters level degree so an additional 2 to 3 years and another 2 for the DNP.

    There is a difference in the education but there exists no evidence that one is superior to the other in a primary care setting.

  58. Larry Wedekind says:

    @ Dr. Sussmen: I applaud your comment to John’s treatise that NP’s should have more freedom to practice within their relative expertise and training. You are the only one among all of the astute Commenters to this Blog who has recognized the truth that “…joining forces with APN’s to develop innovative models of team care will lead to better health outcomes”. This is the key answer to so many challenges that we face during the next 20 years in this country. Challenges including the physician supply shortage and increasing demand posed by the aging babyboomers and our continuing medical cost escalation and national debt challenges. At IntegraNet, we combine the nursing/clinical expertise of NP’s with the more extensive medical expertise of physicians to provide patient centered Medical Homes for our patients and this “team” approach has proven to significantly decrease the cost of healthcare and improve health status for our patients. Our NP’s extend the services of our physicians by going into our patient’s homes and improving medication compliance and medical home compliance; thus decreasing the need for expensive ER visits and hospitalizations. In our experience and as a result of differences in training and expertise, Nurse Practitioners are best utilized as physician extenders in denser populated areas and should be allowed to practice independently in rural areas that lack physician coverage.

  59. Al says:

    @ Larry Wedekind: I don’t take sides with regard to permitting NP’s to practice independently. It depends upon a lot of things and what our ultimate desires are. Maybe we should dummy down the system. Maybe not. We license physicians for certain reasons and give them a license to practice medicine after many years of training. Maybe we should give up licensure as we know it? I won’t take sides on that issue either.

    But, I will take issue with this comment: “.joining forces with APN’s to develop innovative models of team care will lead to better health outcomes”” Where is your proof? One could just as easily say that it would lead to worse health outcomes. I have nothing against NP’s, but worry about their misuse and they have been misused from *every* direction.

    There is no question in my mind that physicians are better trained and are a more select group if academic achievement is the metric being measured. On that basis alone one should assume that favorable outcomes could be negatively impacted if NP’s replaced M.D.’s. If we conclude that physicians are overtrained then you might have a case and it might be better to provide NP degrees than M.D. degrees at least for primary care. But, what we hear all the time is that physician quality should be improved, not degraded.

    That desired improvement needs to occur in primary care as well and it isn’t just with the difficult cases, rather easy ones as well in addition to the difficulty in telling what problems are serious needing more sophisticated care and what are problems are not. IMO we should be trying to maximize quality not minimize it. We should be increasing physician time treating patients by not spending their time meeting crazy rules and by those rules forcing physicians to practice inefficiently and ineffectively.

    Studies have compared non specialist care to the care provided by specialists. I think the Duke heart attack study years ago demonstrated that the higher trained cardiologists provided better care than the non cardiologist M.D. (Internist, FP, and GP) If the logic of that study is extended would not the lesser trained NP have worse results than the better trained M.D.?

    One has to remember that there is a tremendous selection process that is performed prior to an individual being accepted to medical school and generally that individual demonstrates high academic achievement along with work habits that are necessary to produce a quality physician. Most come from the top of their class in college and generally from higher level colleges. I think the selection process is an extremely important factor in producing a quality healthcare practitioner.

    I would consider what happens to the pool of NP’s if because of their ability to practice independently the number of schools increased and the need to fill the classes became an economic requirement for the schools survival. Would the quality of student increase or decrease? Would their dedication be the same as the NP of today? With greater responsibility won’t the errors mount up and since they will be private practitioners won’t they end up having similar malpractice rates as their M.D. counterparts? Won’t they then use defensive medicine to even a greater extent than their M.D counterparts with more training? Would that not mean greater expenditures for the health care system based upon more sub specialist use and more errors that have to be corrected? Alternatively maybe we should dummy down the system and let quality fall a few notches as that would save tons of money. That is the ultimate choice.

  60. Larry says:

    I have a solution to all of this. The medical schools should not be allowed to produce another specialist until they completely close the primary care shortfall. If primary care is so important that barriers, restrictions and unnecessary limitations are placed on quality providers, force the medical schools to fix the problem.

    Or, why don’t the specialists give back to the system and help those that go into primary care to pay off their debts and then to help increase the primary care physician’s income?

    Al, if you read all the posts you will see that 40 years worth of peer-reviewed research shows that nurse practitioners are well-trained and educated primary care providers. Links to some of those studies are provided above.

    No one is arguing to get rid of primary care doctors but the medical associations are offering nothing in terms of ideas that are realistic and cost-effective. Instead of utilizing nurse practitioners they often argue that tele-medicine will expand access. Is a video screen really better than a nurse practitioner?

    The medical associations need to get serious.

  61. Al says:

    Larry, I am not questioning whether or not NP’s are well trained. The question is whether NP’s are trained to replace primary care M.D.’s. If they are then there is no need for a primary care doctor to go to medical school. If medical school is deemed necessary then NP’s assuming the role of the M.D. is simply dummying down the system.

    Please refrain from using the AMA as a voice for practicing physicians. IMO the AMA has one goal in its existence and that goal is entirely self serving and doesn’t represent the physician in the community

    I assume your idea in the first paragraph was merely meant as a bit of humorous sarcasm rather than what you truly believe.

  62. Larry Wedekind says:

    Al: clarification; the post from Larry is not Larry Wedekind. When I post, it will say Larry Wedekind. I don’t know who Larry is….

    Note from my post that I clearly view licensed physicians as much more competent to practice medicine (in general)than NP’s or APN’s for all of the obvious reasons, many of which have already been explained in detail. I would hope that everyone else posting on this Blog understands this truth as well.

    Uwe and John seem to be simply saying that NP’s ought to be able to practice within the limitations of their training without physician supervision for those people who view them as competent to handle their particular healh problem. They believe that the market should dictate their relative value. This concept has a lot of merit. However, I would personally not recommend NP’s for the care of the elderly without some form of physician supervision unless the care is rendered in a rural physician shortage area. I thought I stated this clearly in my post yesterday… note that we do receive significant value from the usage of NP’s as extensions of our very busy PCP’s and in the establishment of medical homes with our PCP’s. Our PCP’s also perceive value from this strategy.

  63. Mary N says:

    Howard is obviously a NP advocate. To state that a NP training is diferrent and imply but equal is very interesting. Wiuld Howard like to have an RN with years of practical experience claim their training is also equivalent to an NP? Funny when you turn the tables the very NP who advocate independence because they feel their training is just differrent but equal to an MD.
    The comments also made that patients are more satisfied with NP because they spend more time and perhaps listen better is not a measure of skill but how ‘nice’ the nurse was. I would rather have a rude and cantankerouse Dr. House treat me, than a sweet talking practitioner that does not have the skills. During my Residency in Internal Medicine there was a a totally incompetent physician who whenever his patients were admitted both Residents and Attendings would cringe because they were usually train wrecks. We often would stabilize these patients only for them to go back to him and eventually find a pre-mature death due to his incompetency. However his patients loved him and would not switch doctors because he had a great bedside manner and patient charm.

    I think the answer is to slacken the law to requirements for supervision but still hold the supervising physician responsible for the patient’s safety. As a physician having supervised nurses an NP/PA’s I know who has good skills, were weaknesses are and who I need to keep a closer eye on.

  64. Mary N. says:

    Mothers who have no medical training read and learn about childhood diseases and what to watch out for in their infants and children (I always listen to Mom’s description and concerns)but does that mean Mom’s also should go out and practice nursing and provide instructions to other patients?
    Why bother having any credentialing board that issues a license at all?
    If NP/PA’s want total independence from peer review that is fine. Let them carry the multimillion dollar malpractice insurances but ‘Buyer beware’.
    Another option is limit the practice to treating very minor conditions such as URI, UTI’s etc. and leave the conditions requiring difficult cognitive knowledge that can only come with years of training and long hours of experience in the hospital as residents.

  65. Mary N. says:

    Just as you would not want a Midwife taking care of of general sick patients, limit the practice of a NP to a specifi area they have further training and expertise.

  66. Rose says:

    The crisis for Primary Care physicians started with program directors disregarding the Constitution and the anti-discrimination laws by refusing residency spots to foreign medical graduates with all the proper documents and all the USMLE exams taken care of. The discrimination is particularly severe for those over the age of 40 despite the fact that many of them are green card holders or naturalized US citizens. Many foreign grads have higher USMLE exam scores than the average US+Caribbean medical school grads and are willing to work in underprivileged areas that are in severe need of physicians. As usual, taking the law in your own hands leads to a disaster.

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    Going to the doctor can be nerve-wracking. Even when your hypochondria is at bay, you show up at your annual checkup all clammy-handed and your blood pressure spikes.

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  70. doctors says:

    How many of the commentors on this post have received care on a continuing basis from a nurse practitioner?

    It is well known that RN’s routinely refuse care from NP’s and insist on seeing a physician.

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