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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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4637 clicks; posted to Main » on 28 Jun 2013 at 11:01 AM (42 weeks ago)   |  Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



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2013-06-28 02:02:45 PM

Meesterjojo: CNA down the street, work 3 nights a week/end, and make $38,000 a year.


This is where I throw up the bullshiat flag. No CNA I've EVER met makes $38k, let alone working three days a week. I've looked at the average wages for CNA's, as I wanted to get my foot in the door of the med field at the lowest level, and it was barely minimum wage. In my state, average CNA pay is just under ten bucks an hour and that's pay that's ten percent above average when it comes to CNA pay.
 
2013-06-28 02:03:56 PM

Yes please: Wangiss: 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.

Came here to say this.

And after reading the rest of the thread you're still admitting it?  If you own up medical school (or more accurately, residency) spots, you won't have an artificial shortage of doctors any more.  You'll have an actual shortage, and those that you do have will be less competent on the whole.  And perhaps marginally less expensive.


Please write grammatically correct sentences in the future.  It will help me understand your point.

Sincerely,

Wangiss
 
2013-06-28 02:11:42 PM

darthaegis: orbister: 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.

I tend to think that has more to do with understanding that, no matter what school or subject of study, you are always going to have somene that graduated last in their class; or in the bottom 25%.

In my experience:  The better the Doctor, the better the bedside manner.


My personal experience doesn't reflect this statement. The worst beside manner I have ever received from a doctor was from a graduate who was in the top 10%. Complete dick who for some unknown reason thought he knew my history and symptoms better than me. It was pure arrogance (guess how I know he graduated in the top 10%? Here's a hint, I didn't ask). As for the shiatty doctors, who knows where in their class they graduated, but the doctors that were just incompetent that I have dealt with tended to have pretty decent to awesome bedside manner, but were unable to have any insight to medical issues. The outstanding doctors that I have known were largely middle of the class physicians. The absolute worst doctors I have had were by and large foreign doctors. There are exceptions to this, but personally, it has been such a huge discrepancy that I only go to U.S. trained doctors now.
All my frustration with the medical field aside, we do a very good job of training our doctors to have some training in bedside manner which is why I will never rail on the requirement that MDs get a BA/BS first. The doctors that I know and personally enjoy talking with (usually not my treating physicians) have all had education outside the medical field which lends them intellect and perception outside of the medical field which translates into better communication and patient empathy. The best treating physician I ever had was a humanities major  (forget which specific field), he could explain things extremely well, took time to listen, and did what I expected him to do.
 
2013-06-28 02:25:53 PM

NuttierThanEver: 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.


As a new PA, i agree.

I started in medicine as an LPN, went on to RN, then BSN, and now PA.
 
2013-06-28 02:27:21 PM

Cletusostomy: I would often take the A-student NP with a lot of experience and knowing their limitations over an MD who doesn't. The general population has little understanding how specific all medical practice is now. If I am hit by a car crossing the street I would take the Trauma RN or ICU NP over a Ph.D/M.D Family Practice MD any day of the week. Even better, I would take a E-4 army corpsman making 20k a year if I got shot over the Top-of-the-class Dermatologist (the hardest specialty to get into...have to be brilliant), M.D./Ph.D making 750k/year. Also, in 14 states NPs and PAs can practice without MD supervision, and that number is growing. Most of the time, that is going to be a good thing, but remember, there are C students in any profession, and you need to have some accounting of that. In the medical field, if you don't do your job right, people can die.


I'm curious.  How did you get shot over the dermatologist?  Catapult, or circus-style cannon, or some kind of railgun?
 
2013-06-28 02:27:41 PM

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.


Thats bc ppl with nursing backgrounds (such as myself) are more interested in the whole big picture, not just what problem needs fixing at the moment.
 
2013-06-28 02:30:00 PM

WhippingBoy: 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?


That's a strawman argument.  NPs, by definition are RNs who are prepared to provide primary and preventative health care services.  It would be expected that they'd have at least a master's in nursing (MSN).
 
2013-06-28 02:34:22 PM
Since when do we hold RN's and MD's at the same level?  Oh right since the corporations and insurance companies started raping the medical profession.
 
2013-06-28 02:35:17 PM

Galileo's Daughter: WhippingBoy: 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?

That's a strawman argument.  NPs, by definition are RNs who are prepared to provide primary and preventative health care services.  It would be expected that they'd have at least a master's in nursing (MSN).


Np and PA are master's degrees.

There are DNSc and DNp which are nurses who ARE doctors.

A DNSc is a research-based degree.


DNP= 4 year bachelor's, 2 years ER experience, Master's degree with 2 years clinicals, then 3 more years school +2 year residency. Every bit the equal of an MD, just focused on different areas.
 
2013-06-28 02:38:29 PM
A PA is a master's degree in medicine, and requires residency training (clinical experience) while in school.


Soooo much poor info in this thread.
 
drp
2013-06-28 02:39:37 PM

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.


And this neatly encapsulates the entirety of the problem:  When the "consumers" of a service lack the knowledge or ability to tell the difference between "excellent" or "good" or "adequate" or "substandard" services, they resort to irrelevant superficial observations.

"My NP is more personable"
"My NP is more willing to talk"
"My NP spends more time with me"

 NOT
 

"My NP prescribed the correct antibiotic" (I have no way of knowing)
"My NP is managing my kid's asthma optimally" (My kid seems to be doing OK, I guess)
"My NP is held to high educational standards (I have no idea what those standards are or how they differ from physician standards)
"My NP correctly assessed my chest pain as being benignly GI in origin and correctly sent me home with some Zantac instead of referring me for costly, painful, invasive testing with nonzero risk" (All I really know is my chest hurt and someone in a white coat did some stuff and said some things)

It's a hell of a coup.  Insurance companies have convinced an awful lot of Americans that not only are their clients getting equal care from cheaper NPs, that they're actually better off with the less educated professional.  Think about that for a moment.  Your insurance company is saving money by sending you to a person with at best 1/4 the training of a doctor, and you're cool with it, because your NP is nice.

As a nation, we sure seem to get the government we deserve, and it appears we're well on our way to getting the "doctors" we deserve, too.

Caveat emptor.
 
2013-06-28 02:49:35 PM
DRP:

All np programs in my state require 3.25gpa's, and practically no one with less than a 3.5 will get in.

Throughout their training, nothing less than 3.0 is passing.
 
2013-06-28 02:59:25 PM
drp:

It's a hell of a coup.  Insurance companies have convinced an awful lot of Americans that not only are their clients getting equal care from cheaper NPs, that they're actually better off with the less educated professional.  Think about that for a moment.  Your insurance company is saving money by sending you to a person with at best 1/4 the training of a doctor, and you're cool with it, because your NP is nice.

As a nation, we sure seem to get the government we deserve, and it appears we're well on our way to getting the "doctors" we deserve, too.

Caveat emptor.


I do not think that is true. I know I certainly hope it is not true. I have not seen any studies, but most Americans realize NPs are of lower quality, but are competent for most basic primary care problems. Do you think a MD is really necessary for diagnosing and treating flu symptoms in 90% of cases? I certainly do not. Nor do I think a MD is necessary for continuing most asthma treatments that have already been diagnosed and started. There are situations where most MDs are vastly over qualified and its a waste of their time and patients money to see them.
Now some of the stuff I have seen NPs do does worry me. I have heard stories of them increasing anti-depressant medication and other high end meds. I agree with MDs that should be out of bounds, but basic triage of common ailments and continuing treatment should be carried over to a NP. Additionally, NPs can also act as gatekeepers and safeguard doctors from over reacting patients by assuaging common concerns which would normally be expected. This all should fall to an NP.
Going beyond what I mentioned above does worry me. I ask you though, if there aren't enough doctors what is the next step? We have limited capacity to make new doctors (and we are already producing at max capacity under current law). I do not know. There are only two realistic options which are to increase doctors or create new professionals to alleviate their demand. As it stands we cannot create new doctors, and therefore the economy is going the only option left open which is new professionals (NPs).
 
2013-06-28 03:00:18 PM
drp:

"My NP prescribed the correct antibiotic" (I have no way of knowing)
"My NP is managing my kid's asthma optimally" (My kid seems to be doing OK, I guess)
"My NP is held to high educational standards (I have no idea what those standards are or how they differ from physician standards)
"My NP correctly assessed my chest pain as being benignly GI in origin and correctly sent me home with some Zantac instead of referring me for costly, painful, invasive testing with nonzero risk" (All I really know is my chest hurt and someone in a white coat did some stuff and said some things)


"My Doctor prescribed the correct antibiotic" (I have no way of knowing)
"My Doctor is managing my kid's asthma optimally" (My kid seems to be doing OK, I guess)
"My Doctor is held to high educational standards (I have no idea what those standards are or how they differ from physician standards)
"My Doctor correctly assessed my chest pain as being benignly GI in origin and correctly sent me home with some Zantac instead of referring me for costly, painful, invasive testing with nonzero risk" (All I really know is my chest hurt and someone in a white coat did some stuff and said some things) 

Perhaps the problem is that doctors have no way of letting us know why their voodoo is better.  Perhaps the fact that when they mess up we will never know until we die or successfully sue them is part of the problem.
 
2013-06-28 03:14:11 PM

Kirzania: Uh, that's my bad. I'm thinking RN and LVN.


well that is completely irrelevant to the subject matter at hand, since they aren't NPs.  next!
 
2013-06-28 03:34:13 PM
The best diabetes care my husband has ever found has been a NP that specializes in diabetes management.  Having them take care of general appointments and relatively stable patients frees the physicians up to treat patients with more chronic conditions.  America needs to invest in getting more students through medical school and nursing school.  There is a glut of nursing student applicants here in California, and many of them end up on waiting lists for years because there aren't enough spots available in the schools.
 
2013-06-28 03:46:00 PM

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.


Why do I need to see a doctor to get a vaccination or get some antibiotics or for a routine physical? If I need open heart surgery or someone to design a cancer treatment regimen then I need to see a doctor but so much healthcare is simple and routine, why can't a nurse practitioner handle those things?
 
drp
2013-06-28 03:49:42 PM

The more you eat the more you fart: DRP:

All np programs in my state require 3.25gpa's, and practically no one with less than a 3.5 will get in.

Throughout their training, nothing less than 3.0 is passing.


The fact that the programs are competitive has precisely zero bearing on the depth or breadth of the training.


Scipio: Do you think a MD is really necessary for diagnosing and treating flu symptoms in 90% of cases? I certainly do not.


I absolutely agree.  NPs can probably handle more than 90% of cases.  How about 95%, just to pull a number out of thin air, just for the sake of conversation?  Small consolation to the 5% left over.

The honest truth is that well over 90% of common complaints don't require any medical treatment at all.  The difficulty is in determining which ones do, and which ones don't.  The cases at the margins are where the aforementioned depth and breadth of physician training catch small problems before they become big problems.

It's a silly argument to say that NPs are good enough for most patients, because most patients are healthy.  Of course the NPs are good enough for them; those patients don't really need medical care at all!  And everyone's healthy ... until they aren't.

NPs can also act as gatekeepers

This is precisely where the risk is, though:  NPs assessing patients without physician input and deciding who the doctor really needs to see.  It should be the other way around:  physicians assessing patients, and deciding which ones can be safely delegated to a closely supervised NP.

I ask you though, if there aren't enough doctors what is the next step?

Expanded use of NPs and other midlevels.  But in closely supervised and directed roles, not the independent practice the insurance companies and nurse PACs are lobbying for.  Insurance companies want to cut costs above all other considerations; nurse PACs want expanded practice rights and independence for their members, because that translates to direct billing and higher wages for their members.  Neither has patient care as a real metric, though both pay lip service to it.  Follow the money.

NPs and other advanced practice nurses have an important place.  They are dedicated, good people.  That place is supervised and directed practice.  More and more of what we're seeing though are advanced practice nurses like NPs and CRNAs acting independently.  The beancounters love it because they cost less.  (Superficially, at least - there are hidden costs from inappropriate referrals, unnecessary testing, missed or delayed diagnosis.)


Wangiss: Perhaps the problem is that doctors have no way of letting us know why their voodoo is better. Perhaps the fact that when they mess up we will never know until we die or successfully sue them is part of the problem.


If you think modern western medicine is voodoo, there is little I can say to convince you.

You are correct that malpractice is a problem, and a big part of the problem is that medicine is very complex, and it's hard for a layperson to know when they're getting good care, or not.  This is why systemic protection in the form of extensive training, careful licensing, and ongoing peer review / credentialing are critical for patient safety.  On the physician side these processes are actually quite rigorous, despite what if-it-bleeds-it-leads news coverage implies.

On the advanced practice nurse side, there is just no comparison.

There are no free lunches.  You get what you (or the insurance company) pay for.  Physicians receive more and better training and are held to higher standards than advanced practice nurses - this is simple objective reality.

If you choose to pay less for care from a NP, because you assess their care to be "good enough" and worth the excess risk over physician care - more power to you.  But you would be well served by carefully considering that
(1) you really aren't qualified to judge the level of their care
(2) NP vs physician care is not equivalent
(3) if it's not you choosing, but an ins co employee ... what motivates that person?
 
2013-06-28 03:55:52 PM

Wangiss: So you think residency is a job people take because they feel like it?  That's original, at least.


No, and I said nothing suggesting that.  People do residency because they have to in order to be a practicing physician.  No one feels like going to the DMV, but they do it because they have to in order to reach the endpoint of getting a driver's license.  Residency isn't much different.  It's pretty much designed to be right at the cusp of tolerability.  If you make it a little better, there still wouldn't be many people who would really want to do it.  If you make it worse, many people would refuse.
 
2013-06-28 04:19:07 PM

Lexx: Jesus Christ, how does any medical professional make less than 20 bucks an hour?  That's 40k/yr!  farking receptionists make 35k+.


Well for starters, you could live in Alabama or one of the other fine, southern states where people think getting paid $9/hr is a goldmine.  But unless you have relatives or know someone outside the state, you can't really escape.  Man I hate Alabama.
 
2013-06-28 04:22:36 PM

Yes please: Wangiss: So you think residency is a job people take because they feel like it?  That's original, at least.

No, and I said nothing suggesting that.   People do residency because they have to in order to be a practicing physician.  No one feels like going to the DMV, but they do it because they have to in order to reach the endpoint of getting a driver's license.  Residency isn't much different. It's pretty much designed to be right at the cusp of tolerability.  If you make it a little better, there still wouldn't be many people who would really want to do it.  If you make it worse, many people would refuse.


Residency is not just another hoop you have to jump through to become a practicing physician - it IS the process of becoming a practicing physician, under the tutelage of more experienced physicians.

People are under the impression that it's some sort of hazing process which the medical fraternity imposes on its junior members, who are already perfectly competent by dint of their extensive medical school training.  After all, anybody can become an instant medical expert just by reading textbooks, a few journal articles, Wikipedia, and WebMD, right?  Just like those lazy-ass doctors are all PGA-level golfers from watching videos of Tiger Woods and reading golf magazines.
 
2013-06-28 04:55:16 PM
I'd rather watch paint dry than read through all the previous comments but--it seems that much of this discussion centers on pay.  Popular fields of medicine for Physicians these days involve medical procedures.  Colonoscopy, surgury, cardiac cath, radiology, pathology studies, etc.  The areas generally open to Nurse Practitioners don't typically involve procedures but are more restricted to medical diagnosis, prescription, and follow-up.  These are the non-procedural areas that Internal Medicine and General Medicine specialties are having a very hard time recruiting physicians to practice.  Reason:  Procedure heavy specialties make hella more money.  Last I checked (citation lacking) there was a huge nationwide shortage of Internal Medicine Physicians.  If physicians want to abandon a necessary specialty like Internal Medicine, they should not be at all surprised when NP's rise to fill the need.  NP's are asking for level reimbursement for functions like office visits, physical exam, patient teaching, follow-up, medical treatment, etc.  Enough NP's filling all the empty primary care slots will save much health care money even if reimbursement levels are equal.  Physicians are all pissy because they believe NP's can't practice medicine as well as they can or more importantly, shouldn't be paid the same for same work.  NP outcome measurements in many areas of chronic disease are as good or better than Physician care.  (Citation needed) Diabetes, Hypertension, and well-woman Gyn are areas I am aware of that NP's have better average outcomes than Physicans.  Personally, I've know and practiced with a thousand physicans and a few hundred NP's.  I'd happily place myself in the care of any of these people.  A few of the physicians would worry me some but I've never met an NP who wasn't very thorough, bright, and professional.  And, importantly, knew when to seek more information or another opinion.
 
2013-06-28 05:13:24 PM

Wangiss: drp:

"My NP prescribed the correct antibiotic" (I have no way of knowing)
"My NP is managing my kid's asthma optimally" (My kid seems to be doing OK, I guess)
"My NP is held to high educational standards (I have no idea what those standards are or how they differ from physician standards)
"My NP correctly assessed my chest pain as being benignly GI in origin and correctly sent me home with some Zantac instead of referring me for costly, painful, invasive testing with nonzero risk" (All I really know is my chest hurt and someone in a white coat did some stuff and said some things)

"My Doctor prescribed the correct antibiotic" (I have no way of knowing)
"My Doctor is managing my kid's asthma optimally" (My kid seems to be doing OK, I guess)
"My Doctor is held to high educational standards (I have no idea what those standards are or how they differ from physician standards)
"My Doctor correctly assessed my chest pain as being benignly GI in origin and correctly sent me home with some Zantac instead of referring me for costly, painful, invasive testing with nonzero risk" (All I really know is my chest hurt and someone in a white coat did some stuff and said some things) 

Perhaps the problem is that doctors have no way of letting us know why their voodoo is better.  Perhaps the fact that when they mess up we will never know until we die or successfully sue them is part of the problem.


This. The NP at least does referrals if its outside their expertise. But if the Doctor is unsure, they just try random things. The worst are imported Doctors, who either treat conditions that don't even exist or blame you for not responding to treatment for the wrong diagnosis.
 
2013-06-28 05:29:42 PM

Parthenogenetic: Yes please: Wangiss: So you think residency is a job people take because they feel like it?  That's original, at least.

No, and I said nothing suggesting that.   People do residency because they have to in order to be a practicing physician.  No one feels like going to the DMV, but they do it because they have to in order to reach the endpoint of getting a driver's license.  Residency isn't much different. It's pretty much designed to be right at the cusp of tolerability.  If you make it a little better, there still wouldn't be many people who would really want to do it.  If you make it worse, many people would refuse.

Residency is not just another hoop you have to jump through to become a practicing physician - it IS the process of becoming a practicing physician, under the tutelage of more experienced physicians.

People are under the impression that it's some sort of hazing process which the medical fraternity imposes on its junior members, who are already perfectly competent by dint of their extensive medical school training.  After all, anybody can become an instant medical expert just by reading textbooks, a few journal articles, Wikipedia, and WebMD, right?  Just like those lazy-ass doctors are all PGA-level golfers from watching videos of Tiger Woods and reading golf magazines.


I agree completely.  I wasn't arguing anything other than the point that people don't do residency because it's fun or something they want to do.  It's a step in the process, not a hoop to jump through.  There certainly arehhoops to jump through for no reason other than jumping through hoops, but that's not one of them.  Butif you make anything sufficiently unpleasant people will stop doing them despite their benefits.
 
2013-06-28 05:34:36 PM
The patients who don't speak Urdu or Hmong, that's who.
 
2013-06-28 05:52:54 PM
Asking a group known for their God Complexes to accept lessors into their ranks, and someone thought this could ever work out well? Nurses aren't any better, either, when they control patient destiny. Medical professionals protect their turf more than Alaskan politicians.
 
2013-06-28 07:31:27 PM

oldfarthenry: 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.).


Is 2-4 kinda like meth, but made out of maple syrup and WD-40?
 
2013-06-28 07:38:21 PM
I have terrible health insurance.  It reimburses at Medicare rates, so doctors aren't exactly lining up to enroll me as a new patient. I've nearly died a couple of times in the last few years due to waiting times (months) to get to see a doctor.  I use the ER as my primary care facility, because my insurance has to cover that.  It's a terrible waste of money, but once I am past the $2500 deductible, it's mainly the insurer's money.

I would be so happy to find a highly-qualified nurse who could see me within a week.  I think they could handle most of the small stuff, prescribe antibiotics, and might have the contacts to connect me with a doctor if they recognize that they are dealing with big stuff.

I don't know how people w/o medical insurance even begin to cope. From what I've read of the anecdotal evidence, most do not.
 
2013-06-28 10:09:52 PM

hardinparamedic: Bumblefark:
Meh...if you have expert knowledge about something, non-experts debating your subject matter shouldn't bother you in the slightest. If you can't persuade others to your point of view, then the problem is probably with you, not your audience.

/besides, even an expert can screw up his facts every once in a while, and get called on it by a non-expert.

People pontificating on a topic they have no idea about, and trying to scare laypeople from doing CPR when it is not only indicated, but the only hope for someone to have a quality life and good outcome by telling them that "doctors don't want CPR and you'll kill them anyway so why try" is not debating.

There is a difference between having an honest discussion and being a flagrant shiat that gives advice that harms people.


Well, it was more a shot at the sort of person that swings by a thread just to pat themselves on the back for being more knowledgeable than the average lay person on a subject (i.e., the original poster). But, for what it's worth: you might be taking the trolls a little too seriously. The average reader isn't a complete idiot -- they can usually distinguish who actually knows what they're talking about.

And, again, if they can't? That's a failure on the part of the (ostensible) expert, not the audience.
 
2013-06-29 10:03:34 PM
I'd rather see a doctor. Thank you.
 
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