Comments on: Nurse practitioners and the PCMH

By: rcentor

rcentor — Sun, 12 Dec 2010 19:39:12 +0000

Point very well made!

By: Suffering from Medical Error

Suffering from Medical Error — Sun, 12 Dec 2010 18:46:07 +0000

I am a medical student who was diagnosed with amebiasis on Friday. The NP at the Student Health Center (there are no MDs or DOs there) gave me a prescription for ciprofloxacin on Friday, after the stool test results came back. Oops! Over the weekend I read up on ciprofloxacin, it is actually empiric therapy when you don't know what the bug is. I even called the NP back and asked about it, since in the Washington Manual metronidazole is listed as the Drug of Choice. Oops! The response was "since you're not THAT sick, I want to try this less irritating drug, and if it doesn't work, we'll put you on metronidazole." So come to find out, after taking drugs for 48 hours, that they were the wrong drugs. Oops!

By: Robert Brockmann

Robert Brockmann — Thu, 08 Jul 2010 23:10:27 +0000

Let's be realistic. The training of a nurse practitioner is highly variable, and includes getting the degree "on line" from the University of Phoenix in about two years of part time work. A typical physician has spent at least seven years, averaging 80 hours a week with no breaks, to earn their credentials. While nurses certainly can contribute meaningfully to the care of a patient, they simply lack the in depth training needed to provide medical care without physician back up. They are not physicians, they are nurses with some additional schooling. I have cared for many patients who have been treated by nurse practitioners, and the errors they make are frightening, and would not be made by a second year med student.

By: NPs Save Lives

NPs Save Lives — Sat, 06 Jun 2009 03:22:56 +0000

Guntermt, I’m not sure who you think has only four years of schooling. I went to school for 7 years to achieve my ARNP degree. I have close to 84,000 dollars of student loan debt and certainly didn’t just jump in here without a lot of training. I don’t want to take over primary care, just be acknowledged that I do as well as some (not all) primary MDs. My collaborating MDs seem to think that I take excellent care of my patients and often come to me for advice. It’s a two way street.

By: guntermt

guntermt — Wed, 03 Jun 2009 01:15:18 +0000

This will be the death knell of primary care internal medicine. If you can arrive at the same career point with 4 years of school vs 11 years of school/ training, why would anyone choose to be a primary care physician. As the leader of a 20 person IM group with primary care, subspecialist, hospitalists and 2 NPs and 2 PAs and 19 years of personal experience, I know what I am talking about. I am appalled at the ACP and will not renew my membership. My colleagues are aghast at this as well.

By: Oskie94

Oskie94 — Mon, 01 Jun 2009 03:31:58 +0000

Outpatient primary care should be delivered by mid-levels with physicians taking on more of a medical director role. The ideal PCMH would have staffing ratios similar to anesthesiologist: CRNA (approximately 1 MD/DO per midlevel). The care of the hospitalized patient should be coordinated by physician-hospitalists who too may do well to utilize midlevels for rounding, discharge planning, etc.

By: Bohdan A. Oryshkevich, MD, MPH

Bohdan A. Oryshkevich, MD, MPH — Sun, 31 May 2009 22:24:05 +0000

There are many excellent posts here. I could agree with all of them. The long tail concept presented by Dr. C is extremely important in this discussion.

The reality is that there is no replacement for intelligence or for learning. Medical doctors certainly do not have the monopoly on either. I heard of a nurse a long time ago at Cornell who was the daughter of one of the authors of Beeson and McDermott, later Cecil Medicine. She apparently worked in the ICU and knew more than any doctor who crossed her path.

The reality is also that it takes years to acquire the knowledge to be a superb internist even in today’s world of CTs, MRIs, and PCRs. Maybe more so since now there is more knowledge to master and more cost at stake. Today doctors do make a difference. One hundred years ago, they did not. So knowledge, concentration, and concern are vital.

Structuring a learning environment so that medical students can master that knowledge and acquiring lifelong learning skills is not easy. If medical students are going to be put into debt and are constantly thinking of how to acquire procedural skills in order to make the living they expect, then the whole process is subverted.

In such cases, medical students and the medical schools which have created this predicament are devaluing the very in-depth education that medical schools seek to offer and that the medical students need in order to differentiate themselves from lesser trained nurse practitioners. This is a case of the medical profession destroying itself from within. Medical school deans have have not valued their charges and undermined their future. Rather, they have confused financial and mental hazing for medical education.

The excuse that there is no money for medical education is ridiculous. We spend more money per capita than any society and have the most indebted students.

Nurse practitioners have filled the vacuum created by medical schools in the cognitive and primary care fields of medicine. Society needs them even though they may be less well trained.

The losers in this situation are not so much the doctors but the patients who would benefit from more skilled doctors.

Medical education has prevented the emergence of real thought leaders and in depth trained clinicians. As David Satcher, the future Surgeon General, said nearly twenty years ago: Indebted medical students will not be capable of leading or reforming medicine in this country.

We are seeing the fruits of that self destruction today.

Bohdan A. Oryshkevich, MD, MPH

By: NPs Save Lives

NPs Save Lives — Sun, 31 May 2009 18:08:17 +0000

I think that any provider is only as good as their capacity to learn and evolve. I have seen both NPs and MDs who were content not to expand their knowledge base and therefore become stagnant. I pride myself in being an excellent diagnostician because that’s what I am most interested in. Not every doctor or NP or PA picks up on the nuances of patient’s complaints and there will be mistakes made. We are all human with weakness and false senses of pride. It needs to stop being a turf war and become about taking care of the patients in the best way we know how which is through collaboration.

By: solo dr

solo dr — Sun, 31 May 2009 15:28:21 +0000

Currently I have nurse practitioner students rotating with me and I worked with nurse practitioners in residency. Currently many specialists have PAs and Nurse practitioners to handle the office visits, while the specialists go off to do procedures. My local hospitals use PAs and Nurse Practitioners on the hospitalist teams, and many primary care physicians have NPs or PAs to help with the office visits for acute problems or updates on chronic problems. Most of them have it setup so that the physician sees the patient every other visit.
I find that PAs, Nurse Practitioners, and residents are similar in that they know some things but do not know as much when the first start in practice.
The practice of medicine requires years of experience beyond book learning and beyond formal school. When PAs, NPs, and residents start out in practice, their knowledge is not as strong as a primary care person with 5 or more years of experience. I think most NPs and PAs can be trained to do much of what we do in primary care. The main fear is that NPs and PAs will takeover much of the easier aspects of outpatient primary care, while primary care physician salaries and fees continue to decrease with no cost of living increase. Currently NPs and PAs are filling a void in areas where there is a shortage of physicians and are are an overall valuable additional to the healthcare team.

By: rolf nesse md

rolf nesse md — Sun, 31 May 2009 14:51:57 +0000

This is a classic I vrs we debate. What is currently wrong in american medicine is that everyone is looking out for his or her specific well being financially. A PCMH is an entity in which the patients well being superceeds that of the individual practitioner. Looking foreward it is clear that if we are to have decent care for all americans , then all of the different medical intelegences, must cooperate together for the patients well being.

I actually understand the PCMH, in that I practice in one already, as a family doctor working for Group Health Cooperative. Our successful model of the PCMH, demands the full use of not only NP’s but PA’s Pharmacists, PT’s and our medical assistants. Each group has added significant new clinical firepower toward the patients benefit. It is about teamwork.

Rolf Nesse MD