On advanced practice nurses and scope of practice

One aspect of science-based medicine (SBM) that I perhaps don't spend enough time and effort on is the intersection of law and medicine for areas in medicine other than the infiltration of pseudomedicine like "complementary and alternative medicine" (CAM) into academia and the never-ending quest of quacks like naturopaths to gain state licensure in states where such pseudomedicine is not licensed and to expand their scope of practice in states where it is. Instead, Instead, I'll look at something going on in my state, namely an effort to expand the scope of practice of a group of medical professionals who actually rate it. Unexpectedly (or maybe it shouldn't be unexpected) and disappointingly, it's a proposal that's had considerable resistance from various physicians' societies in the state. I'm referring to advanced practice nurses (APRNs), often referred to as nurse practitioners (NPs).

Before I go on, it's necessary for me to point out my conflict of interest. No, I haven't received funding from the all-powerful American Association of Nurse Practitioners (whose influence, actually, is dwarfed by state medical societies and various physician groups). I do, however, have a very personal relationship with a nurse practitioner, namely my wife. However, I would point out that she hasn't been an NP that long, and I routinely worked with NPs collaboratively long before the idea of becoming a nurse or even an NP was even a germ of a thought in my wife's brain. Make of that admission what you will as you read on.

Advanced Practice Nursing

Nurse practitioners are different from physicians in that, first of all, they are nurses. However, they are nurses who have undergone advanced training such that they are qualified to manage common medical problems within their scope of practice. Another way that they are different from physicians is that their scope of practice is generally defined by the state laws that regulate their practice. A physician, once licensed in a state, can practice virtually any kind of medicine legally. It is the professional societies, not state laws, that determine the specialization of physicians. In practice, of course, I as a breast surgeon/surgical oncologist, can't practice urology or internal medicine, for example. My hospital privileges don't include them, nor would insurance plans reimburse me for them, nor would malpractice plans insure me to practice these specialties. The law, however, would not stop me. That is how, for example, Stanislaw Burzynski gets away with billing himself as an oncologist, even though he has never completed an oncology fellowship or even an internal medicine residency. (I still can't figure out how he used to manage to get insurance companies to reimburse him for his services.) I would, however, rapidly run into roadblocks actually practicing.

NPs, on the other hand, go into training with a specific scope of practice. My wife, for instance, is a Pediatric NP. In addition, there are Family NPs, Adult NPs, Geriatric NPs, Women's Health Care NPs, Neonatal NPs, Acute Care NPs, Occupational Health NPs, Certified Nurse Midwives, and Certified Registered Nurse Anesthetists. As the AANP describes it:

NP students determine their patient populations at the time of entry to an NP program. Population focus from the beginning of educational preparation allows NP education to match the knowledge and skills to the needs of patients and to concentrate the program of academic and clinical education study on the patients for whom the NP will be caring. For example, consider a primary care Pediatric NP. The entire time in didactic and clinical education is dedicated to the issues related to the development and health care needs of the pediatric client. While medical students and residents spend time learning how to manage adult clients and complete surgery rotations, a primary care pediatric nurse practitioner student’s educational time is 100 percent concentrated on the clinical area where the NP clinician will actually be practicing.

Most state laws are specific about NP scope of practice. NPs who practice outside of their scope of practice can rapidly find their licenses in jeopardy. Confusing the issue is patchwork of laws in different states regulating NP scope of practice. These range from regulating APRNs as licensed independent practitioners, as New Hampshire does, to having in essence no scope of practice beyond that of a registered nurse. Let's compare. In New Hampshire, APRNs have the authority to perform medical evaluation/management; basically, they can diagnose and prescribe treatments within their scope of practice, and there are no requirements for physician collaboration, direction, or supervision. In Michigan:

…there is no statutory or regulatory scope of practice for an NP. According to statute and regulation, NPs have the scope of practice of a registered nurse. Physicians can, by Michigan state law, delegate their authority to perform medical acts.[7] So, because NPs in Michigan cannot perform medical acts without delegation, they cannot be considered licensed independent practitioners under The Joint Commission definition, but they would be licensed independent practitioners under the HRSA definition.

The AANP has a map of the US to show what sorts of practice APRNs have in each state, which range from full practice (like New Hampshire) to restricted practice (like Michigan) to something in between that the AANP calls "reduced practice," like New Jersey, where I practiced for eight and a half years, in which their ability to prescribe depended on collaboration with an MD, but otherwise the NPs could practice nearly autonomously.

Now, you might ask, what does the HRSA have to do with anything? There's still more confusion, because the federal government's definition of an independent practitioner is different from that of many states. The US Health Resources and Services Administration (HRSA) also defines "independent contractor," and, to confuse things still more, its definition conflicts with that of the Joint Commission:

Under The Joint Commission's definition, in states where they are not required to be supervised or directed by physicians, NPs are licensed independent practitioners, but they are not in states where such supervision or direction is required by law. To HRSA, however, all NPs are licensed independent practitioners. The HRSA definition identifies as licensed independent practitioners NPs "or others permitted by law and the organization to provide services without direction or supervision."

As the author of the above article drolly notes, if readers are confused, they are not alone. I don't wish to dwell on this confusion other than to point out that it was Senate Bill 2 in Michigan that got me interested in this topic. The bill is designed to allow NPs to practice independently here (i.e. for Michigan to become like New Hampshire in that respect). More importantly and relevant to SBM, I also have to point out that the opposition to this law from medical professional societies was largely not science-based, and it was because of that opposition that the bill barely squeaked through the Senate only after being amended in ways that arguably watered it down and appears currently stalled in the House. Indeed, that is what disappointed me most of all. I don't wish to dwell on the politics and health policy aspects of NP practice overmuch. Obviously more than just science determines law and policy needs, although it is not outside the range of SBM to point out that, with the projected shortage of primary care physicians over the next couple of decades, better utilizing providers like NPs to pick of the slack should be on the table as an option.

In which physicians protect their turf

An example of the sort of rhetoric being used against SB2 can be found on the Michigan State Medical Society website, there is a link to a pre-packaged letter to send to Representatives, as well as to a statement by the President of the MSMS Kenneth Elmassian, DO, that reads:

Every discussion in Lansing about health care and health policy should start and end with what is best for Michigan patients. The Michigan Senate today picked special interests over the health and safety of Michigan families when they voted to approve Senate Bill 2, which reduces educational requirements for those who practice medicine, risking patients’ lives and sending the signal to health care providers that medical education simply doesn’t matter.

Senate Bill 2 is bad medicine. Lawmakers in the state House should do what the Senate wouldn’t—reject this dangerous special interest legislation and instead put patients first.

On the MSMS Government Affairs YouTube channel are multiple short videos of MSMS members repeating the same dubious arguments:

The letter the MSMS is trying to get doctors to send to legislators, an effort that the Wayne County Medical Society is supporting by including a link to the form on its website (even going so far as to refer to SB2 as a "dangerous bill"), is no better, repeating the same point about fewer years of education, asking:

Consider this: if nurses were given this broad expansion of scope, what would happen if something went very wrong in the course of treatment--something that a nurse doesn't have the education or training to handle? Are you willing to put patients in this precarious situation?

This is a transparently weak argument. To illustrate what I mean, let me ask: What happens when a physician encounters something in the course of diagnosis or treatment that goes very wrong and he doesn't have the training to handle? He calls in other physicians who can handle it! Seriously, by this reasoning, no gastroenterologist should ever be allowed to do colonoscopies because he can't repair a colon if he perforates one, and no cardiologist should be allowed to do angioplasties because he has to call in a heart surgeon to fix the problem with an emergency bypass if he messes up a coronary artery during a balloon angioplasty, a known risk of the procedure. The key is not being able to handle everything, as every physician specialist knows. The key is to be able to recognize when you're in over your head and can't handle a problem and not to be too proud or stubborn to call for help from someone who can handle it. You know who taught me that? Pretty much every surgeon I ever trained under. To quote Harry Callahan, "A man's got to know his limitations." This is true whether that person is a physician or an APRN, and APRN training pounds a knowledge of those limitations home.

I'm not likely to win friends among my peers by saying this, given that multiple Michigan medical societies oppose the bill, but, as a member of the MSMS myself, I do not support the stance of the MSMS, and I was particularly disturbed by the faulty reasoning and fear mongering being used to defeat this bill. Indeed, I'm actually rather embarrassed for Dr. Elmassian, who sounds more like a TV pundit or a politician running for office than a physician with that insulting bit about "special interests." Seriously, I expect the President of my state medical society to make better arguments than that, even if I happen to disagree with his position. After all, I could equally argue that Dr. Elmassian is protecting physicians' special interests against competition, which I rather suspect the MSMS is. Next, the whole argument about "reducing educational requirements" is disingenuous, particularly the nonsense about "sending the signal to health care providers that medical education simply doesn't matter." By that reasoning, I suppose the 17 states in which NPs can practice without physician supervision and the Institute of Medicine, which recommends that NPs be allowed to practice to the full extent of their training don't care about medical education. The main reason that NPs don't have as many educational requirements as physicians is because they specialize from the very beginning, unlike physicians, and they deal with a more limited scope of common problems. The AANP actually has a retort to this argument that I fully agree with:

Head-to-head comparison of educational models is not the appropriate measure of clinical success or patient safety. The appropriate measure is patient outcomes. Forty years of patient outcomes and clinical research demonstrates that nurse practitioners consistently provide high-quality and safe care.

This brings us to the real issue at hand that science can address: Do NPs provide quality care? The AANP and Michigan Council of Nurse Practitioners argue that they do to the point that they should be considered independent practitioners. The MSMS and other medical societies argue that defining the scope of NPs would endanger patients. What does the evidence say? (Sorry about that link.)

The existing evidence base

Unfortunately for the MSMS, the evidence isn't with it. In fact, I find it rather telling that none of the physicians' groups arguing against laws expanding NP scope of practice seem able to cite any science. In fact, they insult my intelligence, and my readers know how much I hate it when someone insults my intelligence. The reason, of course, is because they likely know that existing outcomes research looking at the effects of NPs on quality of care does not support their position. Let's do a quick perusal of the literature, shall we? There are lots of studies; so I have to pick and choose, as well as take a look at a systematic review (non-Cochrane) and a Cochrane review.

One study, a chart review from 2008, compared the family practices in Pennsylvania and New Jersey to examine a single disease: Diabetes. Investigators audited 846 charts of patients with diabetes to compare adherence to American Diabetes Association guidelines for diabetes management between practices that employed NPs, physicians assistants (PAs), or neither. Practices with NPs performed better at providing some types of diabetes care, primarily monitoring tests, than physicians only or physicians with PAs, the latter two of which were statistically indistinguishable from each other. Whether there were confounding factors to account for the differences was not clear. These types of studies do exist in relative abundance. This is not new news, either. Copious evidence for the equivalence of care between NPs and physicians for common conditions that NPs are trained to manage exists dating back at least to the 1970s. For example, the Burlington Randomized Trial of the Nurse Practitioner was published in the New England Journal of Medicine in 1974. This study involved a large family practice in Burlington, Ontario:

…when two family physicians in Burlington, a middle-class suburban town of 85,000 just east of Hamilton, approached the Faculty of Medicine of McMaster University for possible help in introducing this innovation into their practice. For at least two years, their practice had been "saturated" — accepting no new patients or families because of inability to manage an increased case load. The physicians believed that their office nurses, with appropriate additional training, could assume a substantial portion of the responsibilities for primary care.

The NP training was as follows:

Before the study began, the nurses attended a special training program conducted by the schools of nursing and medicine at McMaster University. The emphasis of this program is on decision making and clinical judgment, rather than on procedural skills. The graduating nurse practitioners are qualified to become not physicians' assistants, but co-practitioners, sharing the family physician's responsibility for continuing care of patients. The nurse practitioner learns to evaluate each patient's presenting problems, and to choose from three possible courses of action: providing specific treatment; providing reassurance alone, without specific treatment; or referring the patient to the associated family physician, to another clinician or to an appropriate service agency.

Patients were randomized either to NPs or one of the two family physicians at an allocation of 2:1 to doctors versus NPs, because at the time a case load half of that of a family physician was considered manageable for an NP. The resulting conventional group contained 1058 families (2796 members) equally divided between the two doctors, and the nurse-practitioner group comprised 540 families (1529 members), equally divided between the two nurse practitioners. Over the one year period of the trial, the number of deaths between the two groups was not statistically significantly different, nor was there a difference in physical status in terms of physical impairment, activities of daily living, or disability. The investigators noted a 5% decrease in gross practice revenue, but that was because the physicians were not billing for NP services. It was estimated that if the practice could have been reimbursed for their services, the increased volume of a 22% rise in the number of families under care could have produced a 9% increase in income.

Of course, these two studies are not examples of studies comparing physicians with NPs practicing independently. One of the earlier such studies I became aware of was a randomized study published in 2000 that randomly assigned 1,316 patients to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. (Ironically, the study was published in that mouthpiece of the American Medical Association, JAMA, and is available in full text for everyone, no pay wall.) The outcomes compared included patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. There was no difference in any of the parameters between physicians and NPs, other than that patients with hypertension were found to have a barely statistically significantly lower diastolic pressure at six months when treated by NPs and that patients rated provider attribute scores slightly higher for physicians. The study had limitations, such as being primarily a Medicaid population and thus not necessarily generalizable to an overall patient population and only following patients for a year, but overall it strongly suggested equivalent short-term outcomes.

There are multiple other studies. For instance, a randomized study from 2004 similar to this one found no differences between the groups in health status, disease-specific physiologic measures, satisfaction or use of specialist, emergency room or inpatient service. However, given that there are enough of these studies out there to result in systematic reviews, let's check out the systematic reviews. For example, by 2005 there were enough studies for a Cochrane systematic review on the topic. Cochrane concluded:

The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.

A more recent systematic review from 2011 by Newhouse et al. examined the published literature between 1990 and 2008. Authors included randomized controlled trials or observational studies of at least two groups of providers (e.g., APRN working alone or in a team compared to other individual providers working alone or in teams without an APRN), conducted in the United States between 1990 and 2008, and reported quantitative data on patient outcomes. The review started at 1990 because practice and interventions have changed since before then, and studies in which health outcome effects could not be isolated to the involvement of NPs in patient care were also excluded. They found 69 studies (20 RCTs and 49 observational studies) that met these criteria, of which 37 were about NPs.

Among the conclusions:

  • This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included.
  • Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients.
  • The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.

Although there were limitations in this study, including heterogeneity of studies, limited number of randomized designs, often inadequate descriptions of NP versus physician roles for purposes of the studies examined, and the difficulty in attributing to the NP specific outcomes, at the very least we can say that this review of the literature does not support the contention that expanding the scope of NP practice is likely to result in decreased quality of care. Taken in its totality, the medical literature on the subject does not support the fear mongering about SB2 in which the MSMS has been engaging. It's shameful. There might be political or economic reasons to oppose the specifics of the bill (although, if there are, I haven't yet been convinced of any of them), but there are no scientific reasons to oppose it on the basis of patient safety and quality of care. The MSMS and the rest of the Michigan medical societies who make this argument are, quite simply, wrong. The scientific literature does not support them, and I rather suspect that they know it. If they had any outcomes data to support their fear mongering, they would have cited it. They don't, because there isn't any. Even the Institute of Medicine says so, and I bet any of my colleagues who oppose SB2 can't prove me wrong.

I support increasing the scope of practice of APRNs/NPs commensurate with their education and training. Existing science and my own personal experience that began when I first started working with NPs in 1999 lead me to that conclusion. If there were strong arguments against this from a patient safety standpoint, believe me, I would have grave doubts. (After all, I am a physician, and I recognize that my inherent bias would almost certainly be that physicians provide better care, making me more inclined to take such arguments seriously if they were evidence based.) There aren't, at least none that are scientifically supported by outcomes data, which is why the reaction of my fellow physicians to such measures, which occurs in every state where such bills are introduced, saddens me. It's pure turf protection, nothing more. My recommendation to my state medical societies would be to spend less time trying to shut out APRNs and more time trying to prevent naturopaths from being licensed in Michigan. That would prevent far more harm to patients than the worst fears the MSMS can conjure up about expanding the scope of practice of APRNs.


More like this

(Tangentially related podcast here) Here's the thing: all this talk about arrogance in medicine is a red herring. It's distracting us from the real question that we should all be asking: how do we improve quality medical care? The personality of individual physicians is important, but not very,…
I have just finished taking my last major exam of medical school - Step 2 of the boards (including Step 2 Clinical Skills, or CS, which costs 1200 bucks, requires you to travel to one of a few cities in the country hosting it, and is sealed by a EULA that forbids me from talking about what the test…
One of my duties involves teaching nurse practitioner students. Nursing is quite different from medicine, and many of the linguistic markers of nursing differ significantly from medicine. As more physicians' assistants and nurse practitioners enter the primary care world there will be a bit of a…
I went to see Michael Moore's Sicko last night and it is truly worthy of being seen by every American. I say that knowing how many feel about Michael Moore and his tendency towards spectacle. I hope that people can set aside whatever prejudice they have towards Moore and see this movie. This is…

An even more interesting species for this board, the NP-ND.

Eh, Orac, I'm sorry but I think you've got your blinders on a bit here.

A lot of the evidence you cite for NPs is really not as strong as you present it, either because it doesn't look at appropriate outcomes, or it's not over a long enough period. For example, the Burlington study only looked at outcomes over a one year period - in primary care, I'd be more interested in long term CV outcomes, control of diabetes, etc. One year basically tells me they're not flailingly incompetent (which we all knew already). Similarly, the Cochrane review was quick to say in its conclusion that, "only one study was powered to assess equivalence of care" in all of the studies used. A lot of the NP data either looks at patient satisfaction, or overall cost, without calculating the cost-per-patient (NPs often have smaller practices and take longer with their patients, while still drawing a significant salary).

Am I being protectionist? Absolutely. But I think a lot of primary care providers are seeing the writing on the wall where insurers and HMOs are looking to cut costs, and view NPs as a cheaper equivalent to a primary care doctor.

We have had Nurse Practitioners in the UK for quite a while, and the outcomes have been universally positive. These professionals have demarcations on what they can and cannot do but the expansion of their role has led to overall better care.
I realise that the system across the pond is rather different (way more closed and protectionist for a start) but as long as this is managed correctly then i really don't see what the issue is. Decent review data would be good of course but in terms of time to treatment, ease of access and compliance with NICE guidelines the effects here have been all +

By incitatus (not verified) on 14 Jan 2014 #permalink

Oh, Orac!

I think that your critics will go absolutely batsh!t crazy on you (as if they're aren't already) because you now have declared your COI: you're married to a vaccinator!

" Of course, he supports vaccines: his wife is being paid a *mint* to "damage babies" and "destroy families".

I don't know whether Ms O uses your totally secret(tm) surname or not but I hope that none of the usual suspects go after *her* in her important work.

By Denice Walter (not verified) on 14 Jan 2014 #permalink

I am a New Hampshire resident who has an APRN as a primary care provider. (Not by choice; I was assigned to this person after my previous PCP left my insurance network.) I've only been to my current provider's practice once (for a physical exam), so I don't have a good basis for comparison. But I have at least seen my current PCP. I never saw the previous one in several visits to his practice; his nurse staff handled all of the face to face contact (again, mostly for physical exams, the two exceptions having to do with travel to a malaria endemic region).

I can understand skepticism about whether APRNs are as effective as MDs. But I haven't seen any evidence to the contrary. So while acknowledging Em Jay's point about the limitations of the studies that have been done, I'll agree with Orac here that so far the evidence favors a broader scope for APRN practice. It's not a "beyond all reasonable doubt" position yet, but it does satisfy the "preponderance of evidence" standard.

@Denice: Marriages are public records, so it's easy enough for somebody who knows Orac's not-so-secret identity to find out who Mrs. Orac is. I don't know if any of the usual suspects have actually taken this step, but it's plausible that they already have.

By Eric Lund (not verified) on 14 Jan 2014 #permalink

"It is difficult to get a man to understand something, when his salary depends upon his not understanding it"

-- Upton Sinclair

Kudos to you for making a statement that will no doubt be very unpopular.

I have three comments in favor of Nurse Practitioners. The first is anecdotal, and yes, I know anecdotes =/= data. My personal and family experience with NPs has been mostly positive, on par with the professionalism of MDs. No, they are not as well trained as MDs, but in most cases, you don't need someone with board certification to do a physical exam or checking a sore throat. That leads me into my second and third points.
With the PPACA coming into full effect, we will have more and more people getting access to private practice medical care who previously went to emergency rooms. Doctors can wait to hire other MDs, or can hire NPs to do the initial screens and routine work. The NPs are fully qualified for their specialties, and the MDs can see the more complex patients. Care will expand much faster, as will their private medical practices, but the overall cost per patient will (should) be a bit lower. Everyone wins. (This is the point the MSMS and other medical societies miss. NPs do not have to be competition.)
The third point is that this NP experiment has already been done abroad and in the U.S., just not in the private sector. While I am not intimately familiar with medical care in other countries, I do have experience with the U.S. Navy. The Navy and Marines have medical Corpsmen providing most of the front-line care. In this case, I do mean front-line as in battle lines. (I believe Corpsmen were awarded the highest number of Congressional Medals of Honor, many posthumously.) Corpmen have extensive but limited training. They do the work of nurses in the military, where nurses are often officers in leadership positions. Corpsmen work remotely, often independently, as the only medical caretakers that many service members see for extended periods of time, whether in the field (Marines) or on deployed boats and ships. The military is quite pragmatic and cost-effective in providing medical care, since sick or dead sailors and Marines are not capable of doing their jobs. This is probably the best argument for providing nurse practitioners in the civilian world that I can imagine, but constructive feedback is welcomed.

I've found NPs to be a good solid first line medical provider. They can handle a lot of routine cases -- strep throat, bladder infection, ear infection, is it pneumonia, etc. And that reduces the burden on MDs so they can focus on the more difficult cases. It means patients can be seen more efficiently, in terms of time, resource utilization, and cost. All in all, I'm perfectly comfortable with it, provided the appropriate standards of professionalism and demarcation of duties are followed. And my experience and the data so far give me no reason to doubt that they will be.

By Calli Arcale (not verified) on 14 Jan 2014 #permalink

I do not understand objections to this paradigm. With the trend of more and more MDs & DOs going into specialties than in the past, there is a significant developing gap in primary care providers nationwide. NPs can fill that gap quite well! My group has made very good use of both NPs and PAs in this respect.

Orac sets me to thinking about the distinction between osteopaths and osteopathic physicians. Osteopathy is in its essence a CAM form of treatment, yet there are many practicing physicians in the U.S. today whose credential is a D.O degree rather than an M.D.

Many years ago I was treated by a doctor who had earned the D.O. degree, but whose practice was limited to physical manipulation, more like massage than chiropractic.

Based on my understanding of osteopathic medicine in the U.S. today, I wouldn't shy away from engaging a D.O. as a medical provider, and neither would I shy away from a nurse practitioner or a similar professional. In fact, at the VA clinic where I receive primary care, my PCP is a D.O and the other two PCP-providers are non-M.D.'s, specifically ARNPs.

In the end, a medical practitioner is a service provider. The service I expect is for someone to explain a condition I present with in a way that I can understand, and who can lay out the options I have to deal with it.

By Robert Kelly (not verified) on 14 Jan 2014 #permalink

JerryA has a point - Corpsmen do a great deal of the medical care in the Navy and Marine Corps, and do a pretty good job of it. For that matter, I'm often frustrated at how often Americans seem to run to the doctor for things that don't need real medical intervention beyond first aid to begin with. With that kind of utilization of our medical system, there are a great many patients who could be managed by a calm mother who has CPR and first aid training (no, I'm not over-stepping my abilities; my son's ex-girlfriend was taken to the ER for having a small scratch under her fingernail one time, and for falling and scraping an elbow for another; those people wouldn't even need a nurse, to be honest).

I think those who are against this are immediately jumping to "worst case" scenarios and then adding a lot of hand-wringing, instead of looking at the situation honestly and practically.

My health insurance provider has an "advice nurse" phone line, staffed by RNs (I think - they've got the power to prescribe meds) And that's always the first resource I turn to when I'm feeling ill - and that's how my insurance provider wants it. If the nurse thinks I should see a doctor, then I will, but at least half the time, we sort the issue out over the phone... We all save time, the HMO saves dosh and I get the exact same quality of care I'd have gotten at the doctor's office. Love it.

First, my COI: I'm married to a physician assistant (aka "PA", aka "physician's assistant", aka "physicians assistant", aka "my assistant"... The proper term is "physician assistant" and, in some countries, "physician associate"). I also work occasionally at an urgent care center which employs physicians and physician assistants for primary care.

When a patient comes to that center, based on their chief complaint, we run strep screens, urine analysis, even a CBC or an X-Ray, all before the provider even sees them. Why it takes a medical degree to look at the lab result of a positive strep or a positive urine for a UTI (urinary tract infection) then ask the patient a few questions about their medical history and condition, then prescribe an antibiotic (or give a note for school or work), or slap on a cast and refer them to orthopedics is beyond me. I mean, I'm just a miserable lab tech who's been told by countless physicians not to think, but come on... In our health delivery system, physicians could be better put to work in primary care, where they have to look at the details of the patient's medical history and other concurrent treatments/problems, or as specialists to deal with the complicated stuff.

But to use them to un-impact ear wax or to tell someone they have the flu (go home and drink plenty of fluids), they're pregnant (take your prenatal vitamins and make an appointment with an OB/GYN), they have a UTI (here's an antibiotic you're not allergic to), or that they have diarrhea (in the US, it's self-limited and you just need to tough it out, cowboy). It seems like a waste. Just have the mid-levels do that and, like you said, Orac, train them to recognize when they need the physician's experience and know-how to deal with more complicated stuff.

And, while we're at it, can we train them to have less disdain for the lab tech who is working odd hours while working full time on a doctoral degree?

#9 Mrs Woo:

YES - You wouldn't believe what I was allowed to do in the military as an enlisted member of AMEDS (Army Medical Service) back in the day (late 60s & early 70s)! I did, however, complete the one of the longest training programs (Clinical Specialist MOS91C) in all the military services, second only to Special Forces medic program. I was running “sick call” for minor ailments - I only called in an MD when necessary. I sutured hundreds of young soldiers in the ED and did minor surgery removing warts, moles & cysts, all sent for pathology, of course. In critical care units, I took patient assignments on an equal basis with RNs, mixed and started IVs and poured/passed meds. A lot of the freedoms formerly given to medics & corpsmen faded away with the military’s transition to full JCAHO accreditation. They still get quite a bit leeway in field and shipboard medicine.

More anecdata: I had the same cardiologist–nuse pair for several years at my previous university primary-care group, probably about 20 visits. I think she was an RN at the start, but she was definitely an APN at the end* and basically filling the role of a cardiology fellow, including vetting the EKG and being stuck with the occasional physical exam, which was perfectly appropriate for a known quantity such as myself. The interactions with the cardiologist, who was the section chief of electrophysiology, were also similar in detail and often more lengthy.

The only problem I had with the arrangement was that she was also smoking hot, which was sometimes a bit mortifying for a old, misshapen blob such as myself.

* This might be quite a trick to pull off while working full-time, so perhaps she was an APN all along, but I'm pretty sure that at the outset, she didn't have prescribing privileges.

Well Narad, she's an obvious cardiac stress test!

By sheepmilker (not verified) on 14 Jan 2014 #permalink

I've had the majority of my medical care at a private university hospital for the past five years, as I'm getting PhD at the university in question. And it's been a lot of medical care (eventful five years, do you think the case study I'm the subject of can go on my CV?). Through the entire ordeal, my PCP was an RN, and she did a great job managing all my referrals and seeing me for follow-ups every time I was in the ED and generally keeping me relatively sane through the whole thing :) Now that I'm healthy again, I have sort of 3 PCPs...an RN at student health, a psychiatric APN at mental health, and an MD at allergy, and I've had pretty much the same standard of care from all three (high!).

By hematophage (not verified) on 14 Jan 2014 #permalink

I had many NP students over the years doing rotations with me. I never found them to be as well prepared as medical students. It's actually kind of hard to know your limitations when you have limited experience. To me it has always seemed that PA/NPs would be best employed in more specialized, repetitive settings -- pre-natal checks, colonoscopies, minor surgeries, etc. where they could receive an appropriate amount of training. Humble primary care -- done well -- is actually kind of hard since it requires a broad and deep level of knowledge. Telling somebody that they need 6 weeks of rest and PT requires just as much skill as recognizing that something needs immediate surgical intervention.

My current PCP is a NP. I have had various health care givers in the past - MD/DO, and now a NP. I'm perfectly happy with her so far (only 1 visit). She did a good exam, discussed health issues, encouraged preventative screenings (yeah, colonoscopy and mammogram...sigh...)and didn't go into woo-ville. I'll see her again in a few months for my annual. She is one of many NPs in the GP's office.

Personally, I like the system. If I'm sick enough for a MD, I know I'll be seen by one. If what I need is primary care, with no real issues, why not an educated NP who can do my physical, discuss my medications and current problems, and work with me? I get seen fast, have a thorough examination and time to talk, and the MD office sees a lot of people and no one feels rushed.

Michigan, my Michigan - marching proudly backwards....

I cannot see any objections to having NP's as long as they practice in a group office. Are some of the objections due to, for example, CNM's making at home/out of hospital births? Are people 'afraid' that NP's can open their own offices with a doctor? I have had the same experience as MI Dawn, I would rather not wait an hour to have five minutes with a doctor. I would rather meet with a qualified person that can take down detailed information, and if needed, review it with a doctor. Seems much more efficient to me.

By Scared Momma (not verified) on 14 Jan 2014 #permalink

*open their own office WITHOUT a doctor*

By Scared Momma (not verified) on 14 Jan 2014 #permalink

To clarify a comment made above, NPs are board certified. They must take a national board exam in their specialty area. Board certification is then passed on to state boards of nursing in order for RNs to obtain the APRN license. Once board certified, licensed and hired by an organization, the APRN undergoes a rigorous process of credentialing that allows him/her to bill insurances or Medicaid and allows the NP to be granted privileges at that institution. (This all happens after graduation from an accredited graduate school of nursing; the accreditation criteria for APRN programs are standardized and quite rigorous.)

Secondly, not all primary care is simple and/or straight forward. For example, a comprehensive adolescent physical can be quite complex by the time the provider assesses for things like sexual risk, substance use/abuse, depression/suicidal ideation, determines eligibility for sports participation, manages chronic and acute problems, orders recommended vaccinations, or screens for problems like obesity, hypercholesterolemia, anemia, hypertension, menstrual irregularities, hearing and vision problems. I am an APRN and this is the level of care I provide my adolescent patients at their well visits. I manage a great number of chronic and acute problems on my own with prescriptive delegation from my chairman, but I do have some limitations on my practice that put road blocks in place that do not allow me to meet patient needs. For example, I had a patient who needed continence supplies to be ordered from the medical supply company today, but I had to have an MD sign the script to ensure that insurance would cover the supplies.

I live in a state where NPs can work independently. I've seen quite a mix in the quality of care provided.

I feel that WORST place for an NP is in primary care, where the differential can be huge. A specialists office seeing followup visits is a good use.

Unfortunately, it seems that many, many NPs these days are going straight from nursing school to their NP degree with almost no experience as a practicing RN. They lack the real-world experience necessary to be a good clinician.

Even more frightening, there are now many direct-entry NP programs. These are 3 year programs that you can enter as long as you have a bachelor's degree in any subject. In three years, you're magically an NP. How can a person with 3 years of school be ready to go out an practice independently, when it takes an MD a minimum of 7 years?

By DocInNewHampshire (not verified) on 14 Jan 2014 #permalink

A lot of the evidence you cite for NPs is really not as strong as you present it, either because it doesn’t look at appropriate outcomes, or it’s not over a long enough period.

It's a hell of a lot stronger than any outcomes evidence the docs trying to argue that independent practice for NPs is dangerous have ever presented, at least as far as I've seen. That's because they present no outcomes evidence to support their view because there isn't any outcomes evidence that does support their view, at least none that I'm aware of. Meanwhile meta-analyses indicate there are gaps in our knowledge, but the overall preponderance of evidence fails to falsify the hypothesis that NPs do as well at many kinds of primary care as physicians.


Another ancedote to share, but I think it relates to yours a bit.

A nurse in the department where I volunteer at is currently applying to become a NP. Some of the schools that she heard of for have what you would describe, direct entry to a NP degree, for 3 years. But she said that most of the graduates going from those programs usually do not get hired by hospitals or doctor's offices, and end up working at convenience-care clinics (CVS, Minute Clinic, Walgreens, etc.) or working in one of the nurse care hotlines

Two of the schools to which she applied to requires that the nurses applying to the program have at least 5 years experience in nursing (either at a hospital or clinic) before even being considered for admission, which then would lead into a 2-3 year program to become a NP. I'm not totally sure how experience in a clinical or hospital setting will help a nurse when going into practice, but I don't see where it could hurt too much. (Feel free to correct me). She also told me that the area she wished to get into also would accept her if she got her degree from any of the two schools, provided she completed her degree.

So, I guess I am saying that yes, there are so schools which really don't prepare people to become NPs with actual experience, but there are some other schools which put nurse experience at the forefront.

i am an NP at a Federally Qualified Health Center in a medium city with a large population of medically underserved. I provide primary care to adults with acute and chronic medical conditions--mostly hypertension, diabetes, and back pain. I can tell you my practice outcomes by BP targets/A1c measures/vaccination status/prescribing by condition are at least as good as, if not better than most of the physicians I work with. I'm not being conceited. I wish I were. It takes a tremendous amount of effort to stay current with changing practice guidelines, and many providers just don't do it. It's easier for many providers to write whatever scripts the patient asks for and churn them out as fast as possible. in many cases, that's what the patient wants most as well. simply--most medical providers don't practice EBM.

The most incompetent/s provider I ever worked with was a NP (unfortunately), but she was not trailed too far behind by many of the physicians.

I know that my training and expertise does not match that of a talented, well trained and interested internal medicine physician. But it has also been my experience that I'm at least as good as, if not better than, a mediocre, not-that-interested physician. And, you know, many of them are. :/

We've had NPs here in Australia for quite a few years now, and a few of my friends have gone on to undertake the rigourous training to become recognised and registered as such. (I, on the other hand, went to the dark side of Quality/Patient Safety lol. The cookies, or more correctly, biscuits are very nice).
We have a similar system to Britain in that the scope of practice is determined by the speciality, regulated by the national Registration Authority and state laws, and also overseen by a medical officer. In my clinical specialty of Emergency Nursing, for eg, the NPs run their clinics for a prescribed list of presentations, and can prescribe certain meds/order tests/suture/plaster etc under the supervision of the ED Medical Director. It works very well in ensuring that thse lower priority "GP problem" type presentations are seen nd treated in a timely and appropriate fashion. They are also responsible for following up with their patients as well once they are discharged.
I remember too well, though, the protectionist campaign by the medical associations/colleges here when NPs were first being discussed - the misinformation and misunderstandings were many and huge, with the common argument being 'they want to replace us with cheaper versions!!1!". So what happened was trials - in GP clinics and EDs. Once the peer word of mouth got out as to how good having a NP around was it was realised that, especially with our aging GP population in rural areas and not a lot of young'uns coming in to take up these positions, the NPs actually enhanced service delivery/patient care rather than muscling in on the doctor's turf. It took a couple of years, but NPs are integral to Clinical Service planning and design now, and our patients have reasonable services in place (could be better, but, you know, politics and all that gaff...)
So we have NPs who work really well within our healthcare system over here. I know the US is vastly different, but I don't see the issue as insurmountable.

Having worked in a hospital one of the comments I've heard was from doctors who were bored because "90% of the cases are handling a dozen common issues in which treatment is standardized" . I heard something along those lines many times a day during those times when colds were going around. Days doctors would be seeing several dozen people a day, all with the same symptoms, all of them told the same thing, most given the same treatments.

I've seen doctors mildly embarrassed at hearing of a wreck on the highway after a few days of snotty, hacking, miserable people who they couldn't do much for.

Yet another anecdote...

We are in Canada, home of a publicly funded health care system. Last year at this time, we were in New York on vacation. After having spent the day pushing the stroller for miles, we retired to our hotel room to prepare for dinner. Our then-18 month old daughter said, "Mummy, my ear hurts!" and began to cry.

We have insurance for out-of-country health issues via our work. We call the 800 number on the card. Can we take her to an after hours clinic? No, we must take her to the ER. The ER? She has an ear infection. She's had several. Sorry, go to the ER.

Back into the stroller. At NY Presbyterian's ER, she is seen by a nurse, two NPs, a Child Life Specialist ("I have a personal DVD player for her. Does she like Elmo? We have other choices, if not.") a GP, and, finally, a pediatrician.

The pediatrician listens to her chest (clear, as it was for the preceding nurse, two NPs, and GP) and checks her ears (infected, as they were for the preceding nurse, two NPs, and GP). Prescribes meds. Yet another nurse administers the first dose. We wait a half hour, and leave with a prescription to be filled at a local drugstore.

Anyone care to guess the tally billed to our insurer?

Where we live, this would have played out differently. After hours, ear infection, after hours clinic. NP, examination, prescription, go home. We rely heavily on NPs here for this type of care.

As a physician I see the NP issue as one of lack of knowledge, the old "you don't know what you don't know" issue. PAs and NPs have their uses, but as one of the commenters above stated, it is not on the front lines. The hard part of medicine is not in the treatment descision, but in the diagnosis decision, and that is where the full training of a physician trumps midlevels (on average) every single day. Of course, we have all seen incompitent physicians and midlevels who can run circles around them, but anecdote =/= data.

By Community ED (not verified) on 15 Jan 2014 #permalink

One notes that you haven't actually presented any evidence supporting your assertion that the "full training of a physician trumps midlevels (on average) every single day." In fact, the evidence I have presented, while not ironclad, argues against that assertion rather strongly. You are correct that anecdotes don't equal data (or at least, anecdotes are a very weak form of data), but it's impossible for me not to point out that you haven't actually presented any data to back up your conclusions.

@Community ED, what is wrong with NPs on the front lines, supported by GPs and specialists as needed?

My daughter didn't see a physician until she was 8 weeks old. She was delivered by RMs, her care in the hospital was provided by NPs and RNs, and her care at home for the first 6 weeks was provided by the same RMs who delivered her. Healthy child, healthy mother, supportive care.

Two and a half years later, she's seen our GP maybe four times. The rest of her care has been provided by NPs. Other than her ears, she has been pretty much healthy, and her care has been limited to immunizations and well baby/child checks.

Our GP was called in by our NP to examine her ears -- not because our NP couldn't diagnose otitis media, but because she wanted his opinion on whether or not we should consider tubes (negative).

This is front line care here. It's what our system can afford and it works.

In the three years I've been with this particular doctor's office, I've seen my primary care physician twice, mostly because it's almost impossible to get an appointment with him in under two weeks.

Everything else has been handled by the NP and she's the one I ask for first if I need to come in. I really don't see the difference in the standard of care, and I trust her to escalate the matter to the appropriate level if she feels that I've brought in something beyond her skill set.

I assume my physician trusts NPs as well, otherwise why would he have two on staff?

I thought it wasn't a question about NPs "on the front lines" as it were, but about their independence?

I certainly have no trouble with a health care model of an NP working in concert with an MD to handle the "routine" issues so that the MD can focus on the more challenging issues beyond the scope of the NP. The key to this arrangement, however, is that the NP is working on behalf the doctor, and the doctor bears the ultimate responsibility for their actions. And when I say "responsible" that includes issues of liability.

If the NP is going to be an independent practitioner, than the responsibility falls upon them. Are they liable for their actions? Are they adequately covered with malpractice insurance so that if they DO go rogue or run afoul of the standard of care that people have the ability to take action against them.

An NP who is working outside the scope of their training needs to be able to be held accountable for the bad outcomes, and NOT just in terms of losing their license. They have to be accountable to the patients.

A good example of where this is failing is in midwifery. In particular, lay midwives (CPMs in the US) are running around practicing independently without malpractice insurance, and without any resources. Therefore, when bad outcomes happen due to poor care, the victims have no recourse because lawyers won't take the case. There's no money in it. It doesn't do any good to sue them for everything they got, because they don't have anything.

If independent NPs are able to be held accountable by the public if they practice improperly, required to be properly insured against malpractice, then I don't think there should be a problem.

By Marry Me, Mindy (not verified) on 15 Jan 2014 #permalink

I also see NPs routinely for care in the US. As has been stated it is almost impossible to actually see the primary care MD (the clinic I go to for primary care has several on staff) and the NPs provide quality care. I think they should be allowed to prescribe in their scope of practice, and actually practice as they have been trained!

@Ausduck: it's my firm belief that in order to fix health care here in Australia, someone will need to have to courage to take on and break the most powerful union in the country. And I'm not talking about the various (state) nurses' associations, I'm talking about the AMA.

It's interesting, and frustrating, watching their shenanigans in Queensland at present. About the only idea the Newman govt has come up with that I actually like, is giving pharmacists the ability to administer vaccinations. The AMA is screaming about it, coming up with some ridiculous objections such as pharmacists won't be as rigorous as GPs in checking a patient's medical history. Sorry, if they go through the standard check list that comes with vaccinations, what is the problem?

By Christine (the… (not verified) on 15 Jan 2014 #permalink

All providers need to realize their limitations.

In my, anecdotal, experience NP's are quicker to refer and consult. Personally, this makes me feel somewhat safer with them, as I have personal experience with doctors who will never refer or consult. Everyone involved is human, and no human can be adequately prepared to diagnose or treat every condition.

Honestly, a lot of the anti-APRN rhetoric I've heard has sexist undertones. I've heard people go as far as to say PAs are better than APRNs, despite APRNs having more clinical experience and more specialized training in general.

At last a subject where I can claim some expertise. Apologies for the occasional lapse in grammar and syntax, I'm on my mobile again.

The comparison between Nurse Practitioners and military medical staff is both accurate and valid. Especially within the Naval/Marine service.

I joined the Royal Naval Medical Branch in 1976 and as soon as my training began it was made obvious what that training was for. To work independently on board one of Her Majesty's Frigates or Destroyers (we're affectionately known as 'Doc' or Scablifters!).
Every Doctor in the Fleet knew this and trained us accordingly.

My initial training consisted of (Please bear with me, it's been awhile so I may have forgotten a subject or two);

Anatomy and physiology
Pharmacy and storekeeping
First Aid
Personal and Communicable Health
Nursing *

*After the four months training in the initial subjects we spent another eight months on the wards plus time in all the out patients departments.

Following successful qualification of the first part of training (8 progress tests a week then 8 exams in two days) and when actually dealing with real patients we were deemed qualified to sit in a classroom and learn our final subject;

Diseases and Treatments.

We learned the classic infectious diseases and signs, symptoms and incubation periods. When back on the wards we were taught the same by the surgeons and physicians.

After qualifying we were sent of to a Shore.Establishment to really learn our trade.

Every Doctor in our fleet knew what was expected of us and, if they had an interesting case would bring us in to take us through the signs and symptoms and subsequent treatment.

I suppose what I'm trying to say is, as long as you don't exceed your limitations, and stay within your area of expertise, not only do you provide a service, you release a real doctor to treat the less common maladies.

One thing which we did do (as part.of my on job training) was make sure that every patient came through the treatment room first. I would take a history, S&S and make a ? diagnosis.
If I was wrong the MO would take me to one side and.explain why.

Apologies again if this has been long and.rambling

The hard part of medicine is not in the treatment descision, but in the diagnosis decision, and that is where the full training of a physician trumps midlevels (on average) every single day.

I don't know that anyone disputes this, broadly speaking. Up at #15, with respect to my cardiac APRN, I said "The interactions with the cardiologist ... were also similar in detail and often more lengthy." This wasn't really clear. I meant similar to the interactions with a cardiology fellow (and there were regular med students in the room on more than one occasion, as well).

I didn't mean that they were geared at the same level. One time, the cardiologist came in and went over my recent test results, he noted a 3+ urine-stick heme that rheumatology hadn't bothered to mention to anybody, and he became visibly agitated. This led to a 10-minute mini-lecture to everyone present about exactly why cardio is interested in one's urine, and I got the bonus of a 24-hour collection (only the second time I've been complimented on volume).

This falls into the category of DocInNewHampshire's comment about practice in a "specialists office seeing followup visits," I suppose, but the question is one of NPs working in concert with MDs. If one returns to the actual post, it is "manag[ing] common medical problems within their scope of practice." The phrasing that "PAs and NPs have their uses" suggests belittlement as a point of departure.

Christine@ 36:
I know what you mean re the AMA. They were the most vociferous against NPs whenthe idea was first floated and now are actually the first to defend as time has shown that NPs are not employed instead of doctors.
As to the Qld shenanigans, I was very disapointed with Hambilton's response to the trial of pharmacy vaccinations - the arguments he is using are full of holes!
As I understand it the injections will be given by trained/accredited pharmacists (who will receive the training and be overseen by the Qld Health Trial Committee Medical Officer) and there MUST be two pharmacists on at all times vaccinations are offered. And the only vaccination that is being trialled is the Flu Vax at this time.
These pharmacists will also have to be acrredited in CPR/BLS and the management of anaphylaxis. I challenge Dr Hambleton that all GPs are able to perform ACLS in their surgeries. I also challenge Dr Hambleton;s assertion re cold chain storage - we are talking a pharmacy whose cold chain regulations are way more stringent than GP surgeries.
Perhaps the biggest hole in his argument lies in the fact that he states vaccinations must be overseen by a doctor. My counter to that is what about our school vax programmes? They are administered by Nurse Immunisers, and it's a whole heap of kids all at once. Or the Mother and Baby nurses at community health centres - there are no doctors in these centres when bubs are immunised.
Of course, the comment that patient privacy/confidentiality will be non-existent is just laughable. Many Chemists have availabel private rooms for all sorts of consult/health check services. It's not down out in te shop in the view of everone, and neither will vaccines.
It's just the AMA being protectionist and stirring the pot, just liike they were with NPs. They can take it too far, of course. But there are times, such as with chiropractor assns who are actively lobbying to be considered primary care providers, it's more than warranted.

(my apologies for typos and the mispelling of Dr Hambleton's name - oh for a review button! lol)

@#38 Peebs: It sounds like your Royal Naval Medical Branch training and experience paralleled mine in the U.S. Army. What you relate is essentially the same way the U.S. Army Medical Service functioned in utilization of enlisted medical staff. Soon after I was discharged from the Army in the early 1970s, the U.S. military services began a joint in-service Physician Assistant training program. My particular enlisted specialty was considered a feeder into this program. In retrospect, I would have done well to stay in the Army and pursue this program. As they say, "20-20 hindsight is always clear"!

I've had good experiences with Nurse Practitioners. At my allergist, after the first couple years, my yearly checkup was performed by an NP. I'd rather see an NP quickly, when I'm sick, than wait a week or two to get in to see my regular doctor.

This is all cool, all my contact in the past with NP's was in the military and like PA's I found them all to be professional and competent. So I lookup any NP's at the clinic I go to. Oh, here is one, she has a ND and APRN, wait ND from Bastry?! This is not good. I hope this not a trend.

By Voldemort (not verified) on 17 Jan 2014 #permalink

Here in the rural wilds of Missouri, a CNP opened her own family health care office just down the road from our grocery store. I'm kind of baffled at how she expects to compete, but figure that is her marketing hassle, not mine. She is very aggressive noting that she offers diabetes education, etc. on her sign by the road. Our local MD doesn't do that (though I'm sure the same things are available with him, though probably through nurses at the hospital a half hour away). She also makes sure to get in on the school physical work, of course. Seems nice enough.

This leads me to believe that either she has an MD somewhere that she is "under" for legal purposes or perhaps Missouri has a lot more freedom for them. I know the NP that worked in the town I used to live in had a doctor who she could consult who came into the office approximately eight hours each week. I know that this office doesn't have that arrangement because I was told I was ineligible to be her patient because of the meds I am on (in Missouri nurse practitioners are not allowed to prescribe narcotics). She offered to take me for the rest, but I decided to try the local family doctor instead (highly recommended by the local pharmacist, who has been a dream when it comes to me mixing my own bladder instillations - since she was so professional and helpful, I trusted her).

This doctor impresses me. He actually does labor and delivery - the traditional old-fashioned country doctor thing. Admits and follows his patients in the hospital, etc. Very hands-on. Is open to allowing people to try natural methods of healing, but with labs, etc., to see if there is any improvement and moving them to traditional medication if they aren't improving or the improvement isn't good enough. This has made him someone Mr Woo can work with. Mr Woo was diagnosed with type II diabetes after his stroke, and our PCP allowed him to try his own alternative supplement-based plus weight loss and diet changes program for a few months before having to go to medication. Mr Woo's A1c levels were improved by almost half at this past check-up, so he is allowed to continue doing what he is doing for now.

I'm kind of glad to get a doctor who is open-minded without letting his brains fall out. He's also a friendly midwestern former football playing guy, so he just meshes well with our whole family. That has been another plus.

My cousin, by the way, is a physician's assistant after first doing physical therapy and then an RN. The truth, I think, was that he wanted to be a doctor - his grandfather was one, but at the beginning it seemed like to much. Now he's probably done more than that in hours, but at least he's more of a front-line in patient care.

You did an outstanding job outlining the issues surrounding NPs. As a nurse I once had discomfort about the concept of NPs because I thought they were trying to practice medicine and not nursing. I have come to realize health and caring are concepts that cover both disciplines. MDs do not have a monopoly on health. Caring is not exclusive to medicine or nursing. This overlap means there will be feelings of territorial invasion by both parties. The practices I see where the MDs and NPs take a patient first approach seem quite able to work together.

Physicians have been in a struggle with the role of nurses in patient care for over a century. In the early 20th century only MDs could do blood pressure readings because it was considered a medical skill beyond the capability of a nurse. The early history of NPs were supported by MDs who saw NPs as good ways to pass on lower paying clients and more boring and/or routine tasks to someone else. Now that NPs are becoming a bigger part of US healthcare the MDs are, as expected, staking out their territory with scary stories of subpar care.

Just like with blood pressure readings, medicine and nursing will eventually find compromise over the areas where nursing and medicine overlap.

I'm with Orac on this issue. I've had some (limited) dealings with NPs in office practices. At one time my two PCPs had a NP in their practice and my husband and I were both seen by her for relatively minor medical treatments and were quite satisfied with her diagnosis and prescriptions.

I have a close (younger) friend who graduated with a BSc-Nursing degree, who returned to school to be awarded a MSc-Nursing degree in adult medicine, after seven years employment as a staff nurse in a major hospital's Cardiac Care step-down unit. She passed her Adult Medicine NP boards and has been employed at a large cardiology practice in New York State for the past 10 years. She sees patients (independently) and is often assigned patients to see when the cardiologists in her practice get "backed up".

My husband has been under the care of physicians in another large cardiology practice and several times went to the cardiology practice to be seen by a NP for what turn out to be IV treatments to decrease and steady his heart rate (before he underwent successful right atrial ablation).

When I worked as a public health nurse in the satellite clinics, NPs on staff saw/treated pediatric patients and OB/GYN patients. BTW, those NPs were NOT "vaccinators"; the Registered Nurses administered vaccines...and the Depo Provera birth control shots, ordered by the NPs.

Thanks for the videotapes from the four Michigan doctors Orac. If that's all they've got to defend their indefensible position against NP as primary care providers, it is cringe worthy.

I am wondering if someone could answer the question buried in my comment above:

Do independent NPs carry their own malpractice insurance?

By Marry Me, Mindy (not verified) on 21 Jan 2014 #permalink

Let me add to Orac's comment. Registered nurses who are employed in hospitals (or health departments), are "covered" under their employers' malpractice/liability policies (often their employers are "self-insured).

Every NP who works in private physicians' offices and Registered Nurse that I know, purchases their own malpractice insurance policy. We all felt that we wanted our own malpractice attorney representing our interests, if we were sued.

(Watch for the anecdote)

My daughter's close friend was a relatively newly-licensed RN who worked in the post-surgical Cardiac Care Unit, on the night shift. She was assigned an elderly patient who had undergone CABG surgery and two or three other patients. The physician had ordered full bedrails up (with the hospital bed in its lowest position). The elderly man had post surgical dementia and he managed to climb over the bedrails and fracture his femur. The nurse had her own malpractice insurance, but she was very upset that hospital attorneys tried to foist the blame on her...rather than settling the case for an equitable amount of money.