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(The New York Times)   They make diagnoses, prescribe medications and order and perform diagnostic tests. And since they are reimbursed less than physicians, increasing the number of nurse practitioners could lower health care costs. Who could have a problem with that?   (well.blogs.nytimes.com) divider line 130
    More: Obvious, health care costs, primary care physicians, American Academy of Family Physicians, Robert Wood Johnson Foundation, study design, medications, medical practices, health cares  
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4641 clicks; posted to Main » on 28 Jun 2013 at 11:01 AM (1 year ago)   |  Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



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2013-06-28 09:55:38 AM
Doesn't matter if you have a problem or not. This is how it has to play out. Why go though all the trouble and expense of becoming a doctor when the job market is looking for RN and Nurse Practitioners? True they have less training but people are proving again and again that price is more important than quality.

Which I think is madness, but hey I'm in the minority.
 
2013-06-28 10:25:49 AM

The Stealth Hippopotamus: Doesn't matter if you have a problem or not. This is how it has to play out. Why go though all the trouble and expense of becoming a doctor when the job market is looking for RN and Nurse Practitioners? True they have less training but people are proving again and again that price is more important than quality.

Which I think is madness, but hey I'm in the minority.


NP and PAs can be a great addition to care in underserved areas if (and this is the part that idiot politicians miss) they work closely with a supervising physician to help them deal with areas outside their expertise. I work closely with many NP and PAs and they themselves admit that they are most comfortable dealing with relatively healthy folks with only one or two chronic illnesses and with regular preventative visits.
 For the older population who have 3-4 problems (like diabetes, hypertension, COPD) and multiple meds they admit these folks are out of their areas of expertise. If they are practicing independently without a Internist or Family Practice doctor to ask for advice they will be referring more folks to specialists and then you will see costs of care for a pt managed by an NP or PA zooming back up to where they are with an MD.
 
2013-06-28 10:31:39 AM
So in other words, this is madness?


/great now I can't get 300 out of my head
 
2013-06-28 10:53:28 AM
I'm a doctor.  I employ NPs and PAs.  They're good, but not anywhere near MD level.  They simply lack the fund of knowledge that MDs have.  They are very good at protocolized specific tasks.
 
2013-06-28 10:54:49 AM
Based on recent experience, hell no. My wife was on medical leave for 2 months, seeing an "in-network recommended" NP and getting no progress. This "close supervision" sounded like BS to me, she never got to see the MD. Finally I emphatically pleaded with her to dump this group and go see a doctor recommended by my own doctor. He was out of network and hellaexpensive, but I didn't care about cost at that point. She went to see him for 1 visit and was back to work the next day and doing fine.

Now that's just one personal anecdote, and I realize it probably doesn't work out that way for everyone. But personal experiences like this are a pretty big influence no matter how objective you try to be.
 
2013-06-28 10:57:16 AM

The Stealth Hippopotamus: Doesn't matter if you have a problem or not. This is how it has to play out. Why go though all the trouble and expense of becoming a doctor when the job market is looking for RN and Nurse Practitioners? True they have less training but people are proving again and again that price is more important than quality.

Which I think is madness, but hey I'm in the minority.


I'm with you, I agree to see the Nurse Practitioner at my doctor's office once.  she was of no use, couldn't give me a useful diagnosis and put me on an anti-biotic I didn't need to be on.  she kept asking my opinion.  "You're the medical professional, you tell me!"
 
2013-06-28 11:00:22 AM
Doctors.

(off to RTFA)
 
2013-06-28 11:04:34 AM
I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.
 
2013-06-28 11:05:35 AM

mysticcat: I'm a doctor.  I employ NPs and PAs.  They're good, but not anywhere near MD level.  They simply lack the fund of knowledge that MDs have.  They are very good at protocolized specific tasks.


But do they offload some of your work?  To put it in tech support terms, they're tier 1 or 2 (maybe tier 1 is the internet/your mom/that person at work that looked at the thing on your arm) which takes care of the really common stuff, leaving you with the things they can't solve at tier 3.
 
2013-06-28 11:05:36 AM
Here in lovely South Dakota, I have to drive 3 hours for the rheumatologist. In a state that has a problem with having an MD in many areas, it blows my mind that I have my pain management doctor at a 5-minute walk from my house.

In re: NPs; they are common out here, as I have learned. For a cold or my annual, I have no issue with seeing her. If there is something more urgent, I prefer the MD/DO/whateverthelettersare. Oh, and for vaccinations. Which reminds me, I have to check in on the flu vaccine soon... wonder if the new one is out yet?
 
2013-06-28 11:05:37 AM
My experience with NPs has been nothing short of fantastic.
 
2013-06-28 11:06:49 AM
It probably depends on the issue, I have a relative who has a chronic autoimmune thing that needs to be monitored and he is a big fan of his NP this person listens to him more than the doctors he has seen. The monitoring consists of bloodwork so there's nothing to interpret. I could see wanting to see a real deal doctor if you have some undiagnosed illness that you are trying to figure out.
 
2013-06-28 11:06:53 AM

mysticcat: I'm a doctor.  I employ NPs and PAs.  They're good, but not anywhere near MD level.  They simply lack the fund of knowledge that MDs have.  They are very good at protocolized specific tasks.


Which brings up the question that is on everyone's mind: Does PA = NP?

Don't look at me that way.
 
2013-06-28 11:07:33 AM

sandi_fish: I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.


Same here.  Are pediatrician said to our son, "how's the little girl?"  That was the last straw, now we see a nurse practitioner that actually checks the notes from the previous visit.
 
2013-06-28 11:08:28 AM
The problem we had with the NPs at the urgent care clinic associated with our regular doctor's office is that were getting too creative with their prescriptions and choosing meds that weren't in our formulary. Lots of fun to have to call the doctor's office back when you're standing in the pharmacy to get a script changed so that we could get a drug with an affordable co-pay......

Otherwise, as long as they have a protocol to follow, they work out okay.
 
2013-06-28 11:08:40 AM
As someone who's eventual career goal is CRNA, I fult support my advanced practice nursing brothers and sisters.
 
2013-06-28 11:08:52 AM
same thing at the dentist.  After 20 minutes minutes of cleaning, the tech has seen more of my tooth surfaces than the 15 seconds the dentist took looking.  Sure, he can look at the xrays if he wants.
 
2013-06-28 11:09:00 AM
I'm gonna guess doctors, hospitals, medical schools, and patients.
I currently see a NP to monitor my hypertension, and for regular checkups, but if anything changes dramatically or I get hurt, then I want to see an MD.
 
2013-06-28 11:09:05 AM
Soviet Canuckistan uses nurse practitioners (& triage nurses) in our emergencies wards.
It's great for obvious wounds/ailments (skate-blade slash to the face, 2-4 consumed too quickly, etc.).
 
2013-06-28 11:09:17 AM

The Stealth Hippopotamus: Which I think is madness, but hey I'm in the minority.


I had a MRSA infection once that was treated solely by a NP. I never even saw a doctor. She treated it, prescribed the antibiotics, sent a sample to a lab for culture, and did follow-up visits to make sure it wasn't going to infect my bloodstream and kill me. She was professional, nice, and did an outstanding job.
 
2013-06-28 11:10:35 AM

sandi_fish: I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.


I agree. Nurses are generally far better than doctors at communicating with patients and giving care. Plus nurses will admit when they or the system doesn't know something: doctors are trained never, ever to admit that might ever be fallible.

Doctors are basically highly trained technicians with terrible people skills.
 
2013-06-28 11:11:03 AM
I mean, why would you even want to see someone who's had those extra years of training?
 
2013-06-28 11:11:51 AM
According to the article, NPs want to be paid the same, so where would the cost savings come from?
 
2013-06-28 11:12:50 AM

jjorsett: According to the article, NPs want to be paid the same, so where would the cost savings come from?


Volume.
 
2013-06-28 11:13:49 AM

The Stealth Hippopotamus: True they have less training but people are proving again and again that price is more important than quality.


They don't have LESS training, they have DIFFERENT training.  A NP cannot replace a doctor for about 99% of the activities you really need a doctor for.  Surgery, specialist medical consultation, and referrals are largely things that an NP won't or can't touch with a 50-foot pole, and shouldn't.

What they _can_ replace a doctor for is routine medical upkeep stuff.  They can do periodic exams for most things without supervision, can administer low-difficulty medications like the flu vaccine, and can put you through the preliminary stuff that a doctor would otherwise have to do anyhow to get a basic feel for whether you're sick and how, which is checklist stuff that takes whoever's doing it an hour, but only takes five minutes to read off to the doctor.

NPs are very valuable to doctors, they reduce the workload of routine stuff that doesn't need academic or specialist knowledge, just working knowledge, and they're assistance that doesn't need to be supervised or have their hands held once asked to do something.  My family members in medicine absolutely love their NPs, and most of the ones affiliated with the hospital instead of their office as well. Then, most of the doctors in my extended family got into it to do surgery or diagnose interesting cases, not to grind at repetitive tasks 50 hours for every one that really needs them.

So... I'm not sure where they found the dudes described in TFA.  Honestly, I'm betting the author just made up that reaction whole cloth.

//Though it does sound like the NPs on the network/institution in TFA are being asked to do things beyond their job training/description.  Advanced consultation is a no-no.
 
2013-06-28 11:15:06 AM
They're fine for basic things.  If you have something more complex or need surgery or anything like that, you need an actual doctor.  But NPs and PAs are only supposed to work under the direct supervision of a physician, so there's definitely a limit to how much you can farm out to midlevel providers.  You can try to turn medicine into an industry like fast food as much as you want, as long as you're willing to accept the results.
 
2013-06-28 11:15:10 AM
Hah, now my post looks funny below orbister's. Not that I necessarily disagree with him/her btw.
 
2013-06-28 11:16:12 AM
If nurses wanted to act like doctors and get paid like doctors, they should become doctors - in a perfect world.

The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.
 
2013-06-28 11:17:44 AM

sandi_fish: I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.


Again, this is why most doctors love NPs.  All the things patients do in lieu of just taking your advice and fixing their problem, like demanding you act like you're genuinely pleased to see them and wasting hours of your time in search of empty reassurance... that's stuff that Nurses essentially specialize in, in the same way a thoracic surgeon specializes in heart-related problems.
 
2013-06-28 11:17:53 AM

jjorsett: According to the article, NPs want to be paid the same, so where would the cost savings come from?


Because we don't always get what we want?
 
2013-06-28 11:18:55 AM

Jim_Callahan: The Stealth Hippopotamus: True they have less training but people are proving again and again that price is more important than quality.

They don't have LESS training, they have DIFFERENT training.  A NP cannot replace a doctor for about 99% of the activities you really need a doctor for.  Surgery, specialist medical consultation, and referrals are largely things that an NP won't or can't touch with a 50-foot pole, and shouldn't.

What they _can_ replace a doctor for is routine medical upkeep stuff.  They can do periodic exams for most things without supervision, can administer low-difficulty medications like the flu vaccine, and can put you through the preliminary stuff that a doctor would otherwise have to do anyhow to get a basic feel for whether you're sick and how, which is checklist stuff that takes whoever's doing it an hour, but only takes five minutes to read off to the doctor.

NPs are very valuable to doctors, they reduce the workload of routine stuff that doesn't need academic or specialist knowledge, just working knowledge, and they're assistance that doesn't need to be supervised or have their hands held once asked to do something.  My family members in medicine absolutely love their NPs, and most of the ones affiliated with the hospital instead of their office as well. Then, most of the doctors in my extended family got into it to do surgery or diagnose interesting cases, not to grind at repetitive tasks 50 hours for every one that really needs them.

So... I'm not sure where they found the dudes described in TFA.  Honestly, I'm betting the author just made up that reaction whole cloth.

//Though it does sound like the NPs on the network/institution in TFA are being asked to do things beyond their job training/description.  Advanced consultation is a no-no.



Feel I must object to this. Most MDs have had 4 years college (equivalent to RN degree) then Med school (4 years vs 2 years of NP school) then must do at least 3 years of residency in order to be able to practice with certification.
By my math that is 5 years more training.
 
2013-06-28 11:20:22 AM
Why stop there? Why not let the receptionist make the diagnosis and prescribe the medication? Or the guy who cleans up all the medical waste?
 
2013-06-28 11:21:03 AM
I am currently an LPN working on being an RN-BSN(4 yr degree vs 2 yr) my father was a Family Practice doc. I would love to be an NP but starting in 2015 NPs will have to have their PHD instead of just a Master's Degree. I think this is a great idea...more education is key. Puts me out of the running but no biggie.
I work with PAs at "the home" and they do a good job with the docs coming in once a week.
On the lower nursing end the medical assistants are all that you see in doctors offices anymore. They are pushing out Lpns like me from those jobs. Why pay over 15 bucks an hour when you can pay someone less than 10 for the same type of job.
It's all about cost effectiveness.
 
2013-06-28 11:22:15 AM

herdgirl72: I am currently an LPN working on being an RN-BSN(4 yr degree vs 2 yr) my father was a Family Practice doc. I would love to be an NP but starting in 2015 NPs will have to have their PHD instead of just a Master's Degree. I think this is a great idea...more education is key. Puts me out of the running but no biggie.
I work with PAs at "the home" and they do a good job with the docs coming in once a week.
On the lower nursing end the medical assistants are all that you see in doctors offices anymore. They are pushing out Lpns like me from those jobs. Why pay over 15 bucks an hour when you can pay someone less than 10 for the same type of job.
It's all about cost effectiveness.


Jesus Christ, how does any medical professional make less than 20 bucks an hour?  That's 40k/yr!  farking receptionists make 35k+.
 
2013-06-28 11:22:25 AM

mysticcat: I'm a doctor. I employ NPs and PAs. They're good, but not anywhere near MD level. They simply lack the fund of knowledge that MDs have. They are very good at protocolized specific tasks.


No offense, but in this day and age, all of the medical field is getting out of whack. My grandmother's husband was just admit to rehab but then put in the hospital and then BACK in rehab... all because doctors were just writing out Rxs left and right and it took the nurses to figure out that half of them shouldn't have ever been written because of the interactions with the stuff he was already on. Truly fsked the man up ... I'm talking some serious dementia here.
Then again, any nit can go to community college to become an NP or PA. They push them out like a Chinese assembly line. Same kind of quality too. A clinic I go to, you can tell the majority of them went for the money. I don't know how they passed any kind of exam. Most can't even administer a vaccine properly. (Look, use the alcohol wipe, use gloves, administer the needle WHERE YOU SWABBED.)
/nothing personal
 
2013-06-28 11:23:30 AM

enry: mysticcat: I'm a doctor.  I employ NPs and PAs.  They're good, but not anywhere near MD level.  They simply lack the fund of knowledge that MDs have.  They are very good at protocolized specific tasks.

But do they offload some of your work?  To put it in tech support terms, they're tier 1 or 2 (maybe tier 1 is the internet/your mom/that person at work that looked at the thing on your arm) which takes care of the really common stuff, leaving you with the things they can't solve at tier 3.


This is my opinion as well.  For certain things - like a minor burn injury - I don't see why an actual MD needs to get involved (with all the expense).  If it goes beyond their expertise then they can defer to an actual doctor.
 
2013-06-28 11:24:01 AM

Lexx: If nurses wanted to act like doctors and get paid like doctors, they should become doctors - in a perfect world.

The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.


THIS.
Everything in healthcare is this. Doctors run everything, and they are very good at taking care of themselves and each other.
 
2013-06-28 11:24:10 AM

Lexx: The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.


Right, just like how Michelin artificially limits its star ratings instead of just assigning them to every fry cook who wants one.

Jim_Callahan: They don't have LESS training, they have DIFFERENT SIGNIFICANTLY LESS training.

 
2013-06-28 11:26:08 AM
Doctors?

*reads article*

Yep, doctors.
 
2013-06-28 11:27:19 AM

Yes please: Lexx: The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.

Right, just like how Michelin artificially limits its star ratings instead of just assigning them to every fry cook who wants one.

Jim_Callahan: They don't have LESS training, they have DIFFERENT SIGNIFICANTLY LESS training.


No...it really does happen.  If the medical colleges REALLY cared about patient outcomes and not just limiting the # of doctors entering the workforce, they'd restrict the # of hours/week each doctor in residency works, and lessen the workload for each resident by increasing the number of residents used.  Overworked residents are a huge cause of farkups and bad patient outcomes.
 
2013-06-28 11:28:26 AM
Doctors rage at the idea of someone with less training will take ther jerbs.

I find it amusing that the underlying cause of this rage are their threatened paychecks.
 
2013-06-28 11:29:05 AM

sandi_fish: I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.


Becauase they are employees of the doctors or hospitals, don't have to pay overhead, and have no responsibility to the bottom line.
 
2013-06-28 11:29:23 AM
Why isn't she in the kitchen?
 
2013-06-28 11:29:39 AM
Kirzania:Then again, any nit can go to community college to become an NP or PA. They push them out like a Chinese assembly line. Same kind of quality too. A clinic I go to, you can tell the majority of them went for the money. I don't know how they passed any kind of exam. Most can't even administer a vaccine properly. (Look, use the alcohol wipe, use gloves, administer the needle WHERE YOU SWABBED.)
/nothing personal


Uh, what? I wasn't aware that community colleges gave out master's degrees.
 
2013-06-28 11:29:54 AM

Lexx: If nurses wanted to act like doctors and get paid like doctors, they should become doctors - in a perfect world.

The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.


Bullshiat conspiracy theory is bullshiat.

Really if you think Doctors control medical school admissions you must be smoking something. They are one of the most valuable resources to a University (ie the tuition is sky high, you get the prestige of med school etc). There is no way Universities would allow a secret cabal of the AMA to tell them they cannot open a med school. If they could there is no way in hell one would have been built in the shiathole that is Mt Pleasant Michigan at CMU
 
2013-06-28 11:30:03 AM

bopis: Everything in healthcare is this. Doctors run everything, and they are very good at taking care of themselves and each other.


It's a shame we don't do this for teachers. :( To me, they should be on a similar kind of education:pay ratio.
 
2013-06-28 11:30:33 AM
Well is the business costs go down, by moving to less expensive employes, will my costs go down?

If the NP costs less than an MD, will the paying healthcare customer be getting the same quality of care as with the MD?
If so could we not instead lower MD compensation to achieve the same effect?

OR if the quality of care from an MD is quantifiable better than that of an NP could that become like the $1 menu option for customers?
In the end if NP and MD are = then MD should get less or NP should get more.
If not the same then customers should not be expected to pay the same for NP as they would for MD.

Oh wait i forgot I'm just a pleb in these matters, please let me get back in my proper position here over the barrel.
Forgive my impertinence and continue to enjoy your time at my backside please.
 
2013-06-28 11:30:36 AM
Whether they have an MD, PA or NP following their name, my experience is that they are all incompetent.
 
2013-06-28 11:31:46 AM
Lexx:Jesus Christ, how does any medical professional make less than 20 bucks an hour?  That's 40k/yr!  farking receptionists make 35k+.

I would have made more flipping burgers at McDonald's than I did at my first job as an EMT-IV in 2005.

The only people who get paid what they are worth are RNs and MDs, if at all. My profession still has a LOT of people who do it for free, for example.
 
2013-06-28 11:33:46 AM
For many years the AMA has been severely limiting the number of new doctors graduated, and thus creating an artificial shortage of doctors.

The plan is to turn doctors into executives where their main role is to supervise lower trained and paid NPs and PAs. A doctor as owner of his practice can continue to make a large profit while actually seeing very few of his patients.
 
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