Wednesday, December 17, 2008

Job Postings

I frequently peruse the local NP job offerings and am constantly amazed at the lack of knowledge regarding NP practice within these postings. Below are a few of may favorites:

  • "NP or RN needed" - umm, do you know that there is huge scope of practice difference?!?! Not to put down any of our RN sisters & brothers (after all, we are all RNs first!) However, the scope of practice of each is very different.
  • "Work under the supervision of..." - Get the terminology correct. If you are in NY State (as I am) NPs work in collaboration with our physician colleagues. I can't imagine that this would be a terribly supportive environment.
  • "Competitive Salary" - $35 -40/hour or $60,000 - $70,000/year is not competitive at all, it's insulting.
  • "Must be a team player..." - The word "team" is thrown an awful lot. In the true sense of the word, it would mean that you are an individual grouped with similar individuals for the purpose of a common goal. The real world translation of this is that you will be expected to function in many roles; from performing nursing duties, office duties, and of course, functioning as a clinician.
  • Please don't refer to us as "Mid-Level Providers" or "Physician Extenders" - The care that I give is anything but "mid." I am also not an extender since my practice is my own since I can practice autonomously and competently.

I hate sounding so cynical however, I feel that if someone is looking to hire a nurse practitioner, they should understand the role we play and have a realistic understanding of that role. While I have read many articles that mentions the benefits of having a nurse practitioner (read: increased patient flow, volume, & efficiency), it would behoove one to understand the culturally competence, evidenced-based and caring attributes of the clinician they are posting for.

Wednesday, December 3, 2008

At it again

There is a physician blogger that uses every opportunity that he can to minimize, patronize and belittle the NP role and he is at it again. I refuse to leave a comment on his blog since others who have induce a tirade of back and forth nonsense that gets no where. He can track back to my post and maybe read this blog and maybe gain some relevant insight into NP practice.

I must now return to counting tongue blades since that is as complex as this nurse practitioner gets. One, two, seven....damn!

Friday, November 21, 2008

Salary Results

My informal salary survey had 6 respondents (thank you for responding!)

You can see the actual results on the right hand side of my blog.

Interestingly, 3 of the 6 respondents reported salaries in the $70 - $79,999 category. I know for certain in the NY metropolitan area that salaries are a bit higher than that. One may look at this and say "I can make more money as an R.N." and that would be true. In my experience with my colleagues, NPs don't mainly become NPs for the financial incentives. It is about taking on patient care from a unique perspective - a perspective that synthesizes nursing and medicine, that sets out to be culturally competent, that strives for evidence and that focuses on the whole person.

There are still many out there who do not (nor care to) understand NP practice. I maintain that we are not "physician wannabes" and bring something inherently unique and valuable to patient care.

Thanks again for responding!

Sunday, November 9, 2008

Informal Salary Survey

Hi,

I see a lot of inquires for NP wages. Please take my informal salary survey on the right of the page. Of course, there are many variables to consider such as benefits, bonuses, hourly vs. salaried, etc. I'd just like to get an idea of what others are making and will report on the results.

The survey will be up for a week.

Thanks,
Stephen

Friday, October 24, 2008

Smoke and Mirrors

A NY Times article refers to a new study from the BMJ involving the prescribing of placebos to patients. Many ethical dilemmas are raised with this practice. The "placebos" referred to in this study weren't placebos at all, they were either vitamins or different classes of pain management medications. Wiki defines Placebo as:


... a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity. Any therapeutic effect is thought to be based on the power of suggestion.


The word placebo is Latin for I will please.


Prescribing placebos is only part of the game. There is also the ordering of expensive lab work and diagnostic tests that go hand in hand with the powers of suggestion. I try to be mindful of the tests that I order and explain the risks and benefits of such tests/treatments.

Sure, there have been times when I've contemplated creating my own "S-Pak" in the hopes of creating a magic treatment. But I've found that presenting basic health information, offering rationale and engaging in two-way communication goes a lot further and is much more meaningful than trying to dupe a patient.

Thursday, October 23, 2008

Are We Headed for a Nursing Crisis?

On October 24, NOW on PBS will explore a projected nursing shortage that could impact quality
of and access to care for millions of patients.

Be sure to tune in! Below is the press release:

Show will highlight Innovative solutions in New York City and elsewhere

NEW YORK, September 26 – A U.S. government study projects that by the year 2020, there will be a nationwide shortage of up to one million professional nurses . The nursing shortage is already placing strains on the entire medical system. On October 24, 2008, the Emmy Award-winning newsmagazine NOW on PBS will examine the root causes of this crisis, and innovative efforts to reverse the trend.

Even though qualified nurses are in high demand and hospitals are offering attractive incentives, many are leaving the profession. Even more alarming: few are choosing to teach the next generation of professionals. As a result, tens of thousands of applicants are being turned away from the nation's nursing schools.


The production is supported in part by a grant from the Barbara and Donald Jonas Family Fund (more information is available at: http://jonascenter.org/).

Friday, October 17, 2008

Culture Shocked

A New Jersey jury recently awarded $400,000 to a deaf patient because her physician refused to provide a sign language interpreter throughout their visits. The patient ultimately switched physicians since the steroids she was receiving caused facial edema. The new rheumatologist subsequently took her off steroids and was able to explain that the edema was a side effect of the steroids and not from her illness.

This case presents many ethical dilemmas for the practicing clinician. I have seen other blog posts related to this case. The knee-jerk reaction talks about moral obligations and financial implications for the physician to hire an interpreter that would result in a net loss for the visits (the visits were reimbursed at $49 and the interpreter would cost about $150-200/hr).

Those angles miss the point. Where is the culturally competent care? Cultural Competence is defined as: (via wiki)

... an ability to interact effectively with people of different cultures. Cultural competence comprises four components: (a) Awareness of one's own cultural worldview, (b) Attitude towards cultural differences, (c) Knowledge of different cultural practices and worldviews, and (d) cross-cultural Skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures.

If providers can't communicate with their patients, what good is that?

The physician's malpractice didn't defend the claim and will not cover the liability because quality of care was not an issue. I say, it wasn't?!? What comprises "quality" if the patient doesn't understand what the treatment plan is? Shame on the insurance company. Do they interpret "quality" as only being able to write prescriptions appropriately and treating lab values?

Maybe I have a different idea of quality or competent care. My view involves communication in addition to the science of rendering care. What good is it to treat symptoms and lab values if you can't communicate about the disease process, side effects, complications, etc?

I don't think providers need to bear the ultimate financial brunt of providing culturally competent care. This is where we need real leadership from our elected officials. It is so easy to think of healthcare in terms of patients, nurse practitioners, physicians, insurance companies and medications. Each patient brings a uniqueness to their condition that is undeniable. We have for too long subscribed to the "one size fits all" approach. We need to shift our focus on individualized, evidenced-based care.

Finally, the patient also needs to participate in this process as well (the article states that she reportedly handed the physician a business card of a sign language interpreter). Was that enough? It amazes me there was no middle ground mentioned.

What could've been done differently to have avoided such a drastic outcome? Perhaps an interpreter could've been hired for a specified number of visits. Why couldn't the patient and physician split the cost of the interpreter? What state/federal programs are in place to help these providers & patients in these situations? Did the patient's own health insurance have any programs in place (a quick google search came up with a list of insurance company programs that assisted with these types of situations).

This case also carries American's with Disabilities Act (ADA) implications. It is largely because of the ADA laws why this money was awarded and the case was won. But what about the conditions that don't fall under this Act? Providers still need to find ways to deliver care that is individualized. Having cultural intelligence doesn't make the provider's job easier however, it does enrich one's practice so that patient's needs are appropriately met.

The great thing is if you can't find a provider that is willing to partner in your care, you have the choice to find one that will.

Monday, October 13, 2008

Drive Through Flu Shots


Here is an article about a drive through flu shot clinic in Pennsylvania. The service is targeted at Seniors and health officials devised a system regarding which lane you drive up to and other logistics regarding the vaccination.
At first, I thought it was another gimmick. However the more that I thought about it, it does make sense. I've had a few requests over the years to vaccinate seniors in the drive-by fashion. This always put me in a difficult situation -- not because of the actual injection -- but what happens if there is a reaction and how can I ensure that they wait the recommended 20 minutes post vaccination without driving off into the sunset?
From a public health perspective, it makes complete sense. High-risk patients should get the immunizations and we must examine new ways to make this happen. We certainly can't visit them all in their homes. As long as there is a well-thought out system with policies and procedures in place, ideas such as this will prompt us to deliver quality care in non-traditional ways.
And as a reminder, get your flu shot! Here is a link to the American Lung Association's Flu Clinic Locator. There is plenty of flu vaccine to go around this year.
(image courtesy of Flickr)

Sunday, September 28, 2008

Working Together

Here is a great post from a medical student about retail clinics. Here is someone who clearly understands the need the clinics are filling and more importantly (in my opinion), how nurse practitioners are part of that solution. It's good to see such an un-jaded perspective and how we can all work together in today's complex health system.

Wednesday, September 17, 2008

The 'Diff' iculty With Antibiotics

Today's WSJ Health Blog writes about the infection, Clostridium difficile (C. diff), and how it's becoming known as the 'new' MRSA. The blog writes:



The dark irony is that, because C. diff typically kept in check by the healthy bacteria that live in the digestive tract, people often get C. diff infections after treatment with antibiotics (which kill both harmful and healthy bacteria).



It amazes me to this day, how many people come into the office demanding antibiotics for what are mostly viral infections (which of course, antibiotics do not help). I hear the same stories from my colleagues. Usually, once the side effects are rationalized, most people understand the consequences and we decide that antibiotics aren't indicated for this illness. Of course, this approach takes time and unfortunately, it's much easier to write the script for the antibiotic and not have to take more time out of one's busy schedule to explain this.



Just as unfortunate, is that some providers will criticize those non-antibiotic prescribers and scare patients into thinking they had a much more "serious" case of sinusitis than what was originally diagnosed. (I don't know of an ICD 9 code for "serious sinusitis." Is there such one?) Apparently some equate quality care with how many prescriptions are written or keeping everyone happy.



All of these prescriptions and complications from them just add to the wasteful spending in health care today. Don't get me wrong, if a patient needs an antibiotic, they should have the appropriate antibiotic for that current illness. I've also seen many instances where patients are treated with the "latest and greatest" antibiotic for a condition that could've been treated with amoxicillin. Amoxicillin?!?! Yes, amoxicillin. Some hear amoxicillin and think, "oh that won't work for me." "My body is 'immune' to that." We don't get immunity from antibiotics. The onus should be on the provider to explain and educate our patients with facts, not fiction. Shouldn't we already be doing that as providers? With all of the drug ads that we see everywhere on television, print ads, and the like, I guess I can't fully place blame on patients. But alas, this all takes time and time is money and healthcare is ultimately a business. What a vicious cycle.


See another post here on antibiotics that I posted a few months back.

Sunday, September 7, 2008

Stand Up To Cancer

On Friday night, September 5th, the three major networks aired the telethon, Stand Up To Cancer. It is estimated that they raised over $100 million dollars which according to their website:

...will support research projects conducted by interdisciplinary, multi-institutional translational and clinical research "Dream Teams" and high-risk Innovative Research Grants from which ideas for new Dream Teams may arise. The funds will be administered through the American Association for Cancer Research (AACR), the largest scientific organization in the world focusing on every aspect of high-quality, innovative cancer research.

This is an amazing cause and could've even had a larger impact had it been on more networks and if it aired on a night other than Friday. The show featured patients battling cancer as well as celebrities and their cancer stories.

The show followed actress Dana Delany for her annual breast exam. I was stunned and pleasantly surprised to see the exam performed by a nurse practitioner! The nurse practitioner identified an area of concern and sent Dana for a mammography and ultrasound (see video below). The NPs approach was very calm and reassuring.





Bravo to the producers for documenting this very real scenario and for using a nurse practitioner in this role as the examining provider. It helps to further validate our roles on the healthcare team as NPs are performing examinations like these every day and caring for all types of patients.

In just this past week, NPs have appeared on TV in prime time and in an political ad. That is change that I'm starting to believe in.

Wednesday, September 3, 2008

Obama Ad Narrated by NP

Politico.com reports on a new Obama ad that uses a Planned Parenthood nurse practitioner narrator. The ad happens to be about the pro-choice vs. pro-life debate. The nurse practitioner says:

"“Let me tell you: If Roe vs. Wade is overturned, the lives and health of women will be put at risk. That's why this election is so important,” says the nurse-practitioner who narrates Obama’s ad. “John McCain's out of touch with women today. McCain wants to take away our right to choose. That's what women need to understand. That's how high the stakes are.”"

While my intention is not to turn my blog into a political forum, this certainly is a poignant event for nurse practitioners - to be featured in the national spotlight by the Democratic Presidential Candidate of the United States. It is, however, on a polarizing topic that may further shape individuals views of nurse practitioners either positive or negative.

I have been unable to hear the ad for myself so if anyone can point me to a link, please do so.

Update: Here is a link to the powerful ad: http://audio.cbsnews.com/2008/09/03/audio4411721.mp3

Wednesday, August 20, 2008

What a Wonderful World...

As nurse practitioner-staffed retail clinics continue to open and expand (despite what many recent reports say otherwise), they continue to fall victim to physician-centric comments undermining the competence and professionalism of other health care providers. Am I surprised? Not at all. It has all come to be so routine now. Take for example, a recent article written in the Topeka Capital Journal. The end of the article quotes a pediatrician's take (by the way, the American Academy of Pediatrics opposes the use of retail clinics - whatever that means) on why one shouldn't use retail clinics. The article goes on to say:

As for people who don't have insurance, Cain said there is always a place for them.
"We have plenty of places for people to get care," Cain said. When looking for a physician, Cain advised finding someone who has flexible hours and cares about patients. "I would find a doctor who can provide you with a good medical home," she said. "We specialize in the treatment of children. It's a whole different level of service you're getting."


That sounds like quite the dream world.

I'd like to know what places the uninsured or underinsured can go for care. Does that mean emergency rooms, urgent care centers, under-staffed and over-worked departments of health?

The term "medical home" gets thrown around a lot these days. A true medical home, would be a place that coordinates care, treats conditions and offers preventative care with the right team of providers at the right times and places. It would not mean a solo practitioner as the quote above suggests.

It has become commonplace to end these types of articles with a jab to nurse practitioners. Here they talk about the "level of service" which is exactly that, a jab. Nurse practitioners and those in retail health have and continue offering high quality, compassionate and cost-effective care. Of course this must make some worry since a recent report from the University of Michigan C.S. Mott Children's Hospital National Poll on Children's Health stated:

"Nearly two-thirds of the parents whose children had already used a retail clinic report they were likely to use a clinic again."

Everyone knows that there are plenty of patients to go around. There are good reasons why people are choosing to receive care from a retail practitioner. Those include: convenient walk-in hours & locations, easy access to a healthcare professional, transparency in pricing, print outs of each encounter given to patients at the conclusion of visits and quality care to name a few. The clinics would cease to exist if the care rendered was substandard - and that doesn't appear to be happening. Maybe we can start working together in the interest of patients to attain the highest quality of care rather than protecting turf. Much can be learned from each other. Oh, if it were only that easy. What a wonderful world it would be.

Sunday, August 10, 2008

Ready, Willing and Able

An article about physician assistants and nurse practitioners appears in the NY Times Jobs section. The article does a very good job of explaining both professions though I would disagree with a few of the statements.

Another important difference is that P.A.’s are generalists, while nurse practitioners train in a specialty like family medicine or women’s health. As a result, P.A.’s can switch fields more easily. - I would say that isn't necessarily true. Since the majority of NPs are trained in family health, I think it's just as easy for these FNPs to transition into different roles.

To patients, the two roles can seem very similar. Salaries can be similar, too. The average total income for physician assistants in full-time clinical practice is about $86,000, according to the P.A. academy. The average total income for nurse practitioners is $92,000. - average salary of $92k? I think that sounds pretty high. Most of the NPs that I know are in the $70 - $90k range and I am referring to the metropolitan New York area. A quick jump to salary.com is consistent with that range. There are higher paying jobs in large cities and they are usually affiliated with large hospital systems. The good news is that salaries are on the increase as the demand for advanced practice clinicians is growing.

Finally, the affectionate term of "mid-level" provider is used in the article. I guess I can't fault them since the term is used commonly to collectively describe NPs and PAs. In reality, it is a poor descriptor. It insinuates the care we deliver is somehow not as good as say, a "high-level" provider (not sure who that would be and how one would become such a provider.)What would that make RNs, EMTs, Medics, respiratory therapists, etc - "low-level" providers?!?

Overall, it is great to see these types of articles in the media. The better that the public is educated about our roles, the easier it will be to practice without barriers. Patient's are increasingly choosing to have care delivered by NPs and PAs and will continue to do so as the abysmal health care system sputters along. We afford an imediate solution to this crisis and are ready, willing and certainly able.

Monday, July 21, 2008

More on the Medical Home

Today's New York Times has an article about the Medical Home concept. These projects are becoming more popular as insurers are deciding to cover the costs. The article refers to a patient who visited his very busy physician that missed a stroke diagnosis because of a hurried exam. While mostly inexcusable, it provides a real life example of the issues occurring every single day due to the system's lack of access, communication, reimbursement, and high-quality. While the article doesn't make specific reference to NPs, Senators from New Mexico, Iowa, Alaska and Maine recently discussed expansion of Medical Home projects to include NPs, and other non-physician providers of primary care to lead medical home demonstrations. Senator Bingamin of New Mexico sums it by saying:

Furthermore, nurse practitioners epitomize the delivery of high quality, cost-effective primary care that is crucial to the medical homes model.

Senator Murkowski of Alaska adds:

Nurse practitioners function as partners in the healthcare of their patients, so that, in addition to clinical services, nurse practitioners focus on health promotion, disease prevention
and health education and counseling, guiding patients to make smarter health and lifestyle choices.


The timing of this NY Times article coincides with a recent report by The Commonwealth Fund, a non profit entity. The report found that the U.S. fails on most measures of health care quality, waiting times, and lack of preventative care. This is just more evidence that we must dramatically change the way healthcare is delivered today.

Monday, July 14, 2008

The Solution!

Medgadget recently had the opportunity to interview the president-elect of the AMA, a cardiologist. Someone obviously with the finger on the pulse of primary care. One of the hot topics that he was asked about was the bleak outlook on primary care. This is from the interview:

Q: Here's a question from one of our editors, Nick Genes. He's a resident of emergency medicine at Mount Sinai in New York. Many pundits and experts believe that the US government will improve access to primary care (one way or another) in the next 2-5 years. The Massachusetts experiment suggests there will not be enough primary care doctors to cover the increased demand. Already, primary care doctors are overworked and under compensated, with many leaving the field or choosing specialty training instead. How is the AMA planning to respond to this challenge?

A: ... We continue to mention the importance of trained primary care, and I should also mention the AMA created the scope of practice partnership, because our concern is, that there are those who would rather have the nurse practitioner become the primary care physician. And we don't believe that's fundamentally fair for patients to try and say that a nurse practitioner is the same as a well trained physician who's undergone post graduate training in the practice of medicine.

For those of you unfamiliar with the "scope of practice partnership(SOPP):" is a collaborative effort within the House of Medicine to focus on the resources of organized medicine to oppose scope of practice expansions by non-MDs/DOs that threaten the health and safety of patients.

So the AMA's solution to respond to the challenge of physicians leaving primary care is to denigrate NP practice. I think most NPs acknowledge the fact that we aren't the same as physicians and use that difference as our distinction - we synthesize nursing and medical care. We NPs aren't the only targets here - optometrists, podiatrists, nurse midwives and chiropractors are among other professions that also make the list. In fact, 35 professional organizations formed a joint statement and launched the website, Coalition for Patient's Rights to offer a counterpoint to any inaccurate or misleading information.

The SOPP organizations are also prepared to put their money where their mouth is. It is estimated that at the onset of this movement in 2006, they had a minimum of $470k at their disposal and no less than $300k each additional year. That is a lot of money that doesn't do much to help the single mother without health insurance. Again, this is all under the guise of "protecting the health and safety of the public."

To put those dollars in perspective, my recent post on Remote Area Medical (RAM) operates on a budget of $250k/year and treats about 17,000 patients. Unfortunately, they must turn away thousands of patients since they simply cannot meet the demand.

Sadly, this is another example of creating further barriers to access healthcare. Precious resources are being wasted in this campaign that tries to portray NPs (and other health providers) as being part of the problem in healthcare.

This is the solution? Really?!?

Sunday, July 13, 2008

What's Wrong with this Picture?


Picture this: hundreds of patients braving the elements, lining up for access to a free healthcare clinic, dozens of healthcare professional volunteers offering their time to provide medical, dental and vision services and thousands of dollars in donated medical supplies. Sound like a medical corps serving a third world country? Guess again. Its happening in Tennessee, Virginia and Kentucky.

Tonight, 60 Minutes ran an updated story about Remote Area Medical (RAM). This is an amazing volunteer organization started by Stan Brock. His original intention was to help injured and sick people in desolate parts of the world. Now, a large part of the people being helped are right in our own backyard. What does that say about the state of healthcare today?

The news piece also highlights NP volunteer Teresa Gardner providing women's health services to those in need. She counsels and treats a patient that hasn't followed up in 3 years status post cervical cancer surgery. Sadly, these stories are all too common today. Check out RAM's website in the link above to find out more about the organization and ways to help.

Saturday, July 5, 2008

On Vacation


Hi All,

I will be on vacation for the next week! So, I won't be posting. I know I know for all of the few readers out there you'll just have to find another way to spend your time! :-)

In the meantime, here is a nice press release from the AANP regarding their recent conference that was attended by more than 3000 NPs.

Stephen
(Image via flickr)

Monday, June 30, 2008

Collaboratus

I thought that I'd start this post with a definition of collaborate (via Merriam-Webster On-Line):

Main Entry: col·lab·o·rate
Pronunciation:\kə-ˈla-bə-ˌrāt\
Function: intransitive verb
Inflected Form(s): col·lab·o·rat·ed; col·lab·o·rat·ing
Etymology: Late Latin collaboratus, past participle of collaborare to labor together, from Latin com- + laborare to labor
Date: 1871
1 : to work jointly with others or together especially in an intellectual endeavor

Working jointly with others or together. Isn't that what most providers do when caring for our patients? NPs collaborate with physicians, other NPs, physical therapists, pharmacists, nurses, etc. Physicians also collaborate amongst themselves and with other members of the health care team. I bring this up because the majority of states require a collaborative relationship between an NP and MD. (Conversely, some states use an independent practice model while others use a supervisory one). The regulations among models can vary significantly from state to state. In NY, a written collaborative agreement must exist between the two parties. "Practice agreements must include provisions for referral and consultation, coverage for emergency absences of either the nurse practitioner or collaborating physician, resolution of disagreements between the nurse practitioner and collaborating physician regarding matters of diagnosis and treatment, and the review of patient records at least every three months by the collaborating physician; and may include such other provisions as determined by the nurse practitioner and collaborating physician to be appropriate." Here is a link to a sample collaborative practice agreement.

I came across a relatively new website called, Sermo.com. Sermo has been dubbed a networking site for physicians and claims 65,000 members. For example, MDs & DOs can register and log in to post questions, network and get assistance from others when it comes t0 difficult cases. In essence, this allows physicians to collaborate with one another. I think this is a wonderful idea and a great use of technology to better care for patients. In fact, the AMA has even encouraged physicians to utilize this new tool. Unless you are an MD or DO, you won't get very far with this site since it is currently limited to those degrees only.

So my point to this post is: clinicians collaborate with one another. I don't think we necessarily need a mandate in the way of strict regulation to do this nor should we be limited to any one provider. Ideally, we would have access to a network of experts and specialists (when needed) to better care for patients. (And I think those experts can be across many different disciplines). Collaboration shouldn't be a dirty word when it comes to nurse practitioner practice. We are generally good at recognizing "what we don't know" and getting our patients the correct treatment needed. Wouldn't it be nice if all professions recognized and embraced this concept? Maybe they are starting to.....

Thursday, June 26, 2008

NP-Authored Book on Smart Health Choices

Nurse Practitioner Carla Mills has written a book entitled, "A Nurse Practitioner's Guide to Smart Health Choices." I have read excerpts from the book and intend on picking it up. Carla injects sound advice into managing chronic illnesses and a guideline for maintaining good health.

This could be a great starting point to assist us with motivating our patients onto a healthier lifestyle. It's great to see a true wholestic approach to disease management, health maintenance and promotion.

Check it out!

Thursday, June 19, 2008

Heresy

The WSJ Health Blog posted yesterday: "Some Nurses Land Higher Salaries Than Primary Care Doctors." The gist of the article is that a recruiting firm averaged a nurse anesthetist's salary to be $185k/year opposed to $172k/year for family physicians. Now, I'm not sure if that is a blow to the sad state of primary care in this country or is a blatant smack at nurses.

Is it heresy that nurses can make more than physicians?

I just get the overwhelming sense from the article and its anonymous comments that the nursing profession (and its many specialties) is undervalued, poorly understood and should be akin to the handmaiden image.

Why does it always have to be us vs. them?! Ugh.

Tuesday, June 17, 2008

Calling all Shoppers

Recently, a panel of AMA delegates vehemently opposed the idea of using secret shoppers to evaluate customer service of medical practices. For those of you unaware of what a "secret shopper" is (via Wikipedia):


Mystery shopping is a tool used by market research companies to measure quality of retail service or gather specific information about products and services. Mystery shoppers posing as normal customers perform specific tasks -- such as purchasing a product, asking questions, registering complaints or behaving in a certain way -- and then provide detailed reports or feedback about their experiences.

According to the article, "the secret shopper concept is not being proposed to evaluate clinical skills but the way medical professionals manage relationships with patients, from the process of making appointments to such things as explaining billing practices." Of course, this shouldn't interfere with real patients and take up valuable resources. I'm sure there is a way to address this.

I do understand the slippery slope that this can create (this could be linked with those controversial physician ratings that have gained recent press). However, it is disturbing that a tactic designed to create a better patient experience is so opposed. We've all been there: dealing with a rude receptionist, not having a procedure fully explained, not knowing if insurance will cover it or not, inconvenient hours, not getting a follow-up phone call when promised, unknown lab results (even if they are normal) and this list can go on and on.

Interestingly enough, the University of Vermont's medical school is among schools utilizing a "Mania Day." "One part drama, two parts science as doctors-in-training test their diagnostic skills and bedside manner by assessing the ailments of patients played by real people..." This teaching and evaluation tool has been around since the 1960's and continues to gain in popularity and use. In fact, my NP education included performing pelvic and rectal exams on real live models (aka people willing to experience these extremely uncomfortable procedures in the name of education and training - I don't think I realized how much I appreciated with they did until now! A big thanks to them!). This was an invaluable exercise that helped me to prepare for the real thing. Fans of Seinfeld will remember the episode (The Burning) where Kramer & Mickey act out patient scenarios to medical students:

Our eyes met across the crowded hat store. I, a customer, and she a coquettish haberdasher. Oh, I pursued and she withdrew, then she pursued and I withdrew, and so we danced. I burned for her, much like the burning during urination that I would experience soon afterwards.

That, of course would be gonorrhea.

Ultimately, I believe this will all make for better patient encounters and possibly outcomes. I would ask those resisting this to just pick up the phone, try making an appointment for a routine illness and tell them that you are a new patient without health insurance. Let me know how far you get.

Wednesday, June 11, 2008

It Happens Down Under & Up North Too

It looks like our Australian nurse practitioner colleagues endure similar baseless attacks on quality of care from the physicians they work with. See the article in The Australian entitled, "Bypassing GPs put lives at risk."


"Things will be either missed, as in not detected, or there will be a misdiagnosis, as in something in error," Dr. Capolingua of the Australian Medical Association said."


The easiest thing is always to play the quality card. Scare the public into thinking they will be misdiagnosed or will get inferior care by NPs, though nothing has proven that.


Our Canadian friends subscribe to these tactics too. Right on queue, the Ontario Medical Association chimes in NP quality of care:


"It's a delicate balance: Sure, we want to increase access to health care, but not if it dilutes quality of care. Nurses play a vital part in health care -as a team. You can't replace a doctor with a nurse."


Nurse Practitioner scope of practice does differ slightly outside of the US. Heck, it differs slightly from state to state. NP preparation all includes advanced education, training, licensure, and at least some prescriptive authority onto one's years of nursing experience. NP practice is not about replacing physicians it's about complementing them so that they can manage the more acute patients. Its about working collaboratively with all members of the health care team. It's about the right provider at the right time and place.

Wednesday, June 4, 2008

Warm and Fuzzy

Benjamin Brewer, M.D. writes a regular column in the Wall Street Journal entilted, "The Doctor's Office." Yesterday, he wrote the article, "Primary Care Has Rewards Despite Hassles." I suppose the article is intended to give you the warm and fuzzy's about what it should be like being a primary care physician today - he talks of saving lives and delivering babies.

However, I guess Nurse Practitioners are among the "Hassles" that he speaks of:

"The future competition from retail clinics, various physician extenders and the opening of 200 Ph.D. nursing programs that will churn out "doctor nurses" is just a symptom of our health system's ills, not necessarily a cure for them."

By the way, those programs are Doctor of Nurse Practice (DNP), not PhDs.

I don't believe any of those "hassles" purport to be the cure-all for the ills of the healthcare system. They are however, an attempt to address many of today's dysfunctions. It is wonderful to see those pesky disruptors doing something to improve the situation rather than just sit back and tell stories of the good ole days and maintain the status quo. I also find this backhanded anti-NP remark quite ironic since looking up his office's website, Forrest Family Practice, he employs both a family nurse practitioner and certified nurse midwife. I can't imagine they feel warm and fuzzy after reading his comments. I certainly don't.

Massachusetts' Attempt To Cut Health Care Costs

One has to hand it to Massachusetts for tackling escalating health care costs head on. A bill, that has passed the Senate and will soon be introduced into the House (as reported by The Boston Herald):

"... calls for creating a statewide, electronic medical records database, allowing patients to choose nurse practitioners as primary-care providers, and prohibiting pharmaceutical company sales agents from offering gifts to physicians."

Allowing patients to select NPs as their primary care providers will serve as additional entry points into an already over-burdened primary care system. In addition, the bill will enable patients to experience high-quality, cost-efficient and patient-centered care directed by Nurse Practitioners.

Wednesday, May 28, 2008

Newly Proposed Drug Label System

USA Today reports on a newly proposed drug labeling system that will attempt to enhance information about the effects of medicines used during pregnancy and breast-feeding. The following is from the FDA's press release:

"With this proposal, FDA's goal is to help women, their physicians and their pharmacists have better information about the effects of prescription medicines so that pregnant women, nursing mothers, and breast-feeding infants will benefit," said Rear Admiral Sandra Kweder, M.D., Center for Drug Evaluation and Research, FDA. "This proposal would help make drug labeling a better communication tool, and would potentially have a huge impact on public health and well being for women."

The proposal would eliminate the current pregnancy categories A, B, C, D, and X and replace them with a consistent format for providing information about the risks and benefits of medicine use during pregnancy and lactation.

The USA Today article goes on to say that the FDA has been working on this labeling issue since 1997. I am in full support of this initiative yet at the same time shocked that it has taken 11 years to propose an improved process that should improve medication safety and patient outcomes. I've googled this issue and found information from April 2007 urging the FDA to take prompt action. Here we are, 13 months later still trying to sort it out. Where are the priorities? For an agency that has relaxed the rules (back in 1997) requiring pharmaceutical companies to disclose all side effects and adverse events of medications to now only a brief statement (direct to consumer advertising where companies are spending an estimated $3 billion dollars/year), it seems as if they don't have the public's best interests at stake.

If you'd like to read more on this issue, visit this link that will take you to the FDA website, "Pregnancy and Lactation Labeling."

Also, the FDA will accept electronic comments for 90 days on this proposal at www.regulations.gov. In typical hard to navigate fashion, I cannot locate the proposal on that website in order to submit a comment. I will check back and provide an update when its available. I believe healthcare professionals and patients alike should strongly support this proposal. When can we expect this to go into effect? Here is the FAQ from the FDA website:

"The version of the rule being published today is only a proposal. FDA expects to receive numerous comments on the proposed rule, and those comments will need to be considered carefully before we publish a final rule. This process will take some time."

How many more medication errors and complications must occur before this archaic system is updated? What are we waiting for?!?

Thursday, May 22, 2008

The Medical Home...Are we on to something?

There have been 2 recent articles (one in a Boston publication and one in an upstate New York publication) about the concept of the medical home. This term is thrown around an awful lot these days and means much more than just a solo or group of primary care providers. This is a patient-centered approach to care that uses a coordinated effort by a team of health care professionals focusing on preventative health services right through hospitalizations. You can see the wikipedia definition of medical home here. Professional organizations such as the AAFP, AAP, & ACP (among others) have even adopted formal policy statements on this.

One of the main reasons that this concept hasn't gone anywhere is because the coordination of this type of care (the phone call consults, e-mails, paperwork, etc) hasn't traditional been reimbursed by insurance companies. These new pilot projects are attempting to remedy that. Also encouraging is that NPs are being utilized in this model and are leading the team of professionals.

I am encouraged by this model and anticipate that it will not only improve patient outcomes but will also drive down costs of health care. This is the part that is largely unknown: will it curb the needless spending and duplication of tests/screenings ordered for what is largely considered defensive medicine and will outcomes improve by keeping folks out of the hospital?

Communication and team work are the cornerstones to the success of the model. I am hopeful that healthcare professionals will understand this, work together and keep it patient-focused. Stay tuned....

Friday, May 16, 2008

Recent NP-related Articles

Here is a comprehensive article written in the Physician's News Digest entitled, "Growing role of nurse practitioners." This balanced article gives a synopsis of the current state of the profession and where we might be headed.

Also written this past week was an article about nurse practitioner-staffed retail clinics in Atlanta.

Friday, May 9, 2008

Antibiotics

Here is a great little post about the use and overuse of antibiotics from an ER physician blog, entitled, "We are so screwed." We all know that it is easier to write a script for someone demanding antibiotics rather than explain the risks, benefits and commitment of taking antibiotics. It is so important to not give in. I'll never forget the patient that I saw with a 1-2 day history of nasal congestion and very mild symptoms. I went into my whole routine of explaining why I felt her condition was viral and antibiotics weren't necessary. After that whole little dialogue, I asked her if she had any questions and she says, "Uhh, can't I just get a Z-Pak?" What??? Were you even listening for the past 3 minutes??? (FYI, I did not write for the Z-Pak.) I'll never understand the rationale of wanting to take a medication that isn't clearly indicated, can cause gastrointestinal issues, can be expensive and is usually a commitment for 10 days (that's 1/3 of a month!)

I also came across a blurb about the CDC's "Get Smart" campaign. This campaign has been around since the mid 1990's and its main goal is to increase public education about the proper uses of antibiotics in the hopes of driving down the expectation of receiving antibiotics for common respiratory illnesses (common cold, ear infection, sinus infection, bronchitis, etc) and to help curb antibiotic resistance. The CDC has even designated October 6-10, 2008 as "Get Smart About Antibiotics Week" to increase the awareness among patients and clinicians, so mark your calendars!

Have a great weekend and Happy Mother's Day to all Mom's out there!

Thursday, May 8, 2008

Some Brief History

Once again, an article about retail health appears on the WSJ Health Blog site and the discussion ends up being about NPs versus MDs. Under that thread, a whole firestorm is set off when someone by the alias of "real doctor" claims that patients have returned to his office following visits to the retail clinics because they "were not treated appropriately." I certainly felt the need to respond to this arrogant attack on NPs and did so as "Real Nurse Practitioner."

So what follows is the typical rhetoric from purported physicians and includes: if you want to be a doctor go to medical school, being a doctor means that you have to spend 11 to 15 years of post graduate training after high school, wearing a stethoscope and a white coat doesn't make you a doctor and the list goes on.

NPs don't become NPs to "play" doctor. This is a profession that was borne from a need of primary care and pediatrician shortages in under-served areas. In 1965, the first NP program was headed up by nurse pioneer Loretta Ford and pediatrician Henry Silver at the University of Colorado to address this need. The rest as they say is history. However, we still are subject to inaccurate and baseless attacks from other "professionals." If the care that we provide is unsafe, prove it. If we are harming patients rather than helping them, I'd take a step back and examine my role in the profession. As far as I know, these doomsday scenarios aren't happening. In fact, it's the contrary. Patients are choosing to see nurse practitioners because of the way that we synthesize nursing and medical care. We focus on the whole person when treating specific health problems and provide extensive health information on the impact of those problems on patients, their families and the community. We work as part of the health care team to care for our patients.

I would not nor would I insinuate that NP care is better than physician care. It's different yet has the same goal and outcomes. It wasn't long ago that osteopathic physicians were treated as second class citizens in medical communities and some still are. I guess it would be naive of me to think that NPs would be accepted with open arms. However, I didn't think that we'd be subject to school yard, sand-box type attacks.

Tuesday, May 6, 2008

NPs in Pennsylvania

An article about nurse practitioners from Pennsylvania's timesleader.com appears on their website today, "Popularity of practitioners growing." The article discusses an NP practice in Kingston Pennsylvania, Women to Women, that specializes in women's health.

It's great to see more and more NP practices gaining headlines. It's also great to get support from our elected leaders such as PA Gov. Ed Rendell. He was integral in expanding the NP role in Pennsylvania in the hopes of making health care more accessible. It certainly seems like they are well on their way.

Patients that utilize our services appreciate the access, the patient-centered approach and the high-quality care that NPs are known for. It's also encouraging that other members of the health care team are becoming increasingly aware and accepting of our roles on the team in an attempt to fill in the many gaps in health care.

Tuesday, April 29, 2008

Tips for Choosing a Primary Care Provider

Today's Newsday featured an article that included attributes to look for when choosing a primary care physician (I added the word "provider" :-). Long Island Nurse Practitioner Peggy O'Donnell was interviewed for the article and added some sound advice:

"Certainly you want somebody who's not going to only speak in lay language but do reflective listening. You really have to have someone who hears what you're saying to them."

There are many practical and common sense tips for patients. Clinicians should also be able to reflect on the advice from the article. It serves as a great reality check for us to ensure that we are properly in touch with our patients' reasonable questions and concerns.

Friday, April 25, 2008

Front Lines

There are 2 notable articles that I've come across that highlight initiatives by nurse practitioners to deliver care to relatively under-served populations.

The first is from a program out of Norwegian American Hospital in Illinois. Their "Care-A-Van" is a mobile unit, staffed by pediatric nurse practitioner Patricia Carr, that will visit area schools and provide the following services, all for free: ..."routine child immunizations, required physicals, hearing and vision screenings, pulmonary function testing, asthma assessments, childhood health promotions, in addition to injury prevention and education." What a wonderful opportunity for NP-directed care.

The second article is about nurse practitioner, Melanie Ryan Morris, owner and operator of The Cure Health and Wellness clinic in Texas. "The clinic focuses in preventative health care for working-class patients -- both uninsured and insured -- and particularly women." The location of her clinic was specifically chosen to provide access primarily to the small business workers in the community. The majority of her visits thus far have consisted of STI screenings and women's health exams.

It is wonderful to see nurse practitioners on the front lines of health care providing desperately needed access. Though, I'd like to see more acceptance for NPs providing care to all, not just the under-served. Its disconcerting when the attitude towards NPs caring primarily for the under-served is "its better than no care at all." Why is it OK to care for these folks? Is it because they aren't important enough?

Monday, April 21, 2008

Some Do Get It

Here is a link to a Medical Economics column, "How I built a successful medical practice in under seven years." What struck me about the article is Dr. Kurt Hunter, a Wyoming physician, and the utilization of physician assistants (a total of 4) in his practice.

Each PA sees about 40 acutely ill patients daily, and I see the more complicated cases—usually about 15 per day, with visits lasting 20 to 40 minutes.


This sounds like a perfect scenario and a true team-oriented approach to primary care in this community. The physician should be taking on the more complex cases leaving the more routine cases to the PAs (though we all know, nothing is routine). Not surprisingly, other physicians in the blogosphere have criticized him for "giving away primary care to mid-levels" which just shows the stubborn mindset of some.

According to the article, Dr. Hunter was also integral in supporting Wyoming legislation that increased the number of PAs that he can directly work with from 2 to 3 and then from 3 to 4. How refreshing it is to see a truly integrated team approach to primary care in this underserved community!

Friday, April 18, 2008

The Breaking Point?



There is lots going on in the world of health care lately and I wonder if we've reached the breaking point. We saw stories just this past week on insurance companies refusing to pay for hospital mistakes, on-line health records not having to comply with HIPPA laws, problems with access to health care and the primary care physician shortage, a move towards concierge medical practices (where physicians reject insurance companies and patients essentially pay a retainer to be a part of that practice), and finally, drug companies using ghost writers to make their studies appear better than what they actually are.

Even more troubling is the lack of solutions to address all of the above. I constantly ask myself, when will this get better and what is it going to take? This a time when we need our elected leaders to take "ownership" of these issues and for some out-of-the-box solutions from the private sector. The status quo is no longer a viable option.

Monday, April 14, 2008

Rhetoric

Here is a recent article written in the AMA newsletter entitled, "Advanced-practice nurses seek wider scope in 24 states: Physician leaders fear that expanding the range of services nurses can provide may threaten patient safety."

It includes the same old rhetoric against NP practice that they've been using for at least the past 15 years. I found this old press release from the American Association of Colleges of Nursing in response to a December 1993 report from the AMA Board of Trustees questioning independent practice by advanced practice nurses. The response clarifies and corrects the erroneously written material.


Sadly, 15 years have passed and we are in a no better, if not much worse, health care crisis. Instead of working collaboratively for a solution that will attempt to address the health care shortfalls, some choose to recycle old baseless, inaccurate arguments.

(Image is Plato-raphael from wikipedia, "rhetoric.")

Saturday, April 12, 2008

NP in Parade Magazine's Salary Survey

Syracuse, NY native Archie McEvers, NP, will appear in Sunday's annual Parade Magazine "What People Earn" insert. Archie was chosen from millions of submissions and joins celebrities appearing in the survey.

Archie, who has worked at University Hospital in Syracuse for the past 20 years is quoted as saying, ".. I hope that people will at least recognize what a nurse practitioner is..." This coverage in the Health Care section of the Parade survey certainly helps!

See below to view the news clip from the local Syracuse, NY station.
video

Wednesday, April 9, 2008

Shameless Plug

I came across this website of Healthy Trust Immediate Medical Care in Wheeling, Illinois. This appears to be an urgent care center. On a post from 4/8/08, they have an entry entitled, " The difference between Immediate Care and Retail Care." Now, I understand that healthcare is a business and retail clinics can impede on urgent care centers. Most of the retail clinics that I am familiar with (at least the ones that are NP staffed) do not purport to be an emergency/urgent care clinic. But, once again NPs become the brunt of the argument against the clinics.

Here are examples from their posting: "These centers are generally staffed with nurse practitioners not true physicians." I don't think NPs try to pass themselves off as "true physicians" or even false physicians for that matter. The vast majority of NPs are proud of the fact that we are nurses first and bring that added level of caring to our encounters. We also enjoy collaborating with physicians to solve and/or refer challenging cases.

"Let say you visit your neighborhood retail clinic with a sore throat. It is common for a doctor, or medical assistant to take a strep test. At an Immediate Care Clinic with an on site lab you will know within twenty minutes whether you have strep or not and should be prescribed an antibiotic. At a retail clinic they have to send the culture out over night to lab for analysis. So if they prescribe you an antibiotic you may not need it. It is the same thing with something as simple as the flu. A clinic with an on site lab can make a true diagnosis while you wait, and treat you accordingly while a retail clinic has to send the culture out to be tested."

Hmm, they have the ability to grow a culture in 20 minutes?? Wow, that is some technology! Because if they are referring to a rapid strep antigen test, it looks like the retail clinics know how to do those too (here and here). The suggestion here is that the NPs in retail health are prescribing antibiotics that may not be needed.

You wanted more? Yes, there's more!

"Obviously a real Physician can provide a broader range of services than a medical assistant or Nurse Practitioner." Obviously? Oh, and the hint again is NPs are not "real physicians." (did you catch that one?) It's also cute how they threw in medical assistants in the same breath as NPs.

"Perception is almost everything to the public. Even though the care you receive is more comprehensive, faster, and overall less expensive at a true Immediate, or Urgent Care Clinic, patients are often lured in by the convenience a retail clinic can offer, and of course the large marketing campaigns which promote them at the major chains they reside in." Translation: you are stupid if you go to a retail clinic because you can get caught up in fancy shiny advertising and the convenience while receiving less comprehensive care by an NP.

Here is their "conclusion" for this obvious advertisement for their center:

"Both models can work depending on the scope of treatment needed, but a true Immediate, or Urgent Care Clinic has significant advantages over a simple Retail Clinic for the average consumer. Since the costs are about the same, and both have convenient locations and hours, the consumers best choice is always to be seen by a true physician at a site that provides for on site lab, and X-Ray. "

I have an alternate conclusion to offer: How about partnering with a retail clinic instead of bashing the Nurse Practitioners that work in them because its obvious that they have a focused scope of services and that a fair number of patients won't be eligible for their services. I would even glean that NPs working in retail clinics would prefer to refer to an urgent care center rather than to an emergency room for obvious reasons. But oh well, I guess they can't see past that. What's that saying.....You can catch more flies with honey than vinegar? This is an awful lot of vinegar.

Speaking of Physician Staffed Retail Clinics...

An article was written in The Baltimore Sun about Rite Aid's plans to open physician-staffed retail clinics in the Baltimore & Washington, D.C.

Bravo to the author for presenting balanced information regarding NP practice. There are even quotes from Mary Jo Goolsby, director of research and education at the American Academy of Nurse Practitioners:


"We're part of the health care team," said Mary Jo Goolsby, director of research and education at the American Academy of Nurse Practitioners. "Nurse practitioners take care of acute minor illnesses, but we also have long taken care of complex chronic conditions," such as heart disease and diabetes.

"We have the ability to recognize when something else is indicated and know when further" care should be recommended, Goolsby said. "There is a huge body of evidence that has looked at the quality of care provided by nurse practitioners, and it's considerably demonstrated that we provide safe, efficient, cost-effective care of high quality."


Monday, April 7, 2008

Scare Tactics

An article about retail clinics in Michigan appeared on today's Crain's Detroit Business website. For those of you not having the pleasure of reading the typical retail clinic article in mainstream media, I'll summarize 95% of them for you now:

1. They usually start out talking about the fast growth of retail clinics. Some even throw in a "joke" of getting a tetanus shot where you shop for toilet paper.
2. Sometimes they interview an actual patient seen in the retail health setting. The patient usually has sinusitis or streptococcal pharyngitis and remarks about the convenience of the clinic's hours, location, price, accessibility, etc. The patient's experience is positive and state they would return again in the future.
3. Here it comes: "Doctors feel threat, have concerns, are skeptical," etc. This is the part for good ole fashioned nurse practitioner-bashing. Here is my case in point:

"Nurse practitioners play an important role in health care, but, in general, they don't have the skill or experience to (properly) diagnosis a patient." That quote is compliments of Dr. Chris Bush, board member of the Michigan State Medical society.

Let's dissect that: "Nurse practitioners play an important role in health care." I'm not sure what role NPs could play in health care if we aren't diagnosing & treating illnesses, writing prescriptions, ordering and interpreting lab results, coordinating health care services, since that IS what NPs do. Also, everybody knows that whenever you preclude a sentence with "but," you essentially negate what you just said.
Back to dissecting: "...don't have the skill or experience to (properly) diagnosis a patient." Here is the recurring intimation that nurse practitioners are not smart enough or can't critically think to autonomously care for patients. Is that a hit on the education that NPs must endure to become licensed and board-certified? Or is that merely the opportunity to scare patients reading the article that NPs shouldn't be providing care to anyone?

The other notable part of the article is: "In addition, many medical concerns handled by a walk-in clinic can either be treated at home by the patient, such as the common cold, or should be something that is handled by a physician, such as vaccinations, Bush said." Wait, vaccinations?!?! Maybe that should've been the part where he said "CABG surgery" or "craneotomy." But vaccinations? Oh sorry, I'm forgetting, we aren't capable of thinking with that level of complexity. He also just threw all of his urgent care physician colleagues under the bus with that statement. I'm sure they appreciate the support.

What is sadly missing from the vast majority of these articles is the NP response to the questions of NP-directed care. If the very care is being questioned, why isn't there an opportunity to defend it? Would it have been that hard to contact a representative from the Michigan Council of Nurse Practitioners or the Michigan Nurses Association?

I'm sure similarly written articles on retail health will continue appearing in mainstream media. My exception is with the relentless attacks that the clinicians (usually NPs and/or PAs) take as the main "problem" with the clinics. Perhaps local & national NPs need to maintain vigilance in setting the record straight when these derogatory articles are written about our profession. Believe it or not, there are a few physican-only staffed retail clinic operators out there too. I never hear the same negative arguments holding true for them as to the NP model.

Unfortunately, the vast majority of folks won't likely read this positive NP article appearing on medpage.com, National Kidney Foundation: NPs Help Hypertensive Patients with Kidney Disease Improve BP Control. Kudos to NP Naima Ogletree of the Henry Ford Health System in Detroit for her involvement with this preliminary, retrospective data review.

Thursday, April 3, 2008

Physician Practicing Nursing??

Just when I thought that I've seen it all: An article appears about a physician and his 'new' practice, Wellnessmart. This is a retail-based practice where "...people walk in and get what they need."

The article goes on to say:

"The store doesn't sell vitamins or medication but markets preventive health services like screenings that may tell a 33-year-old man he has a 17 percent chance of a heart attack over 30 years. It sells annual checkups, weight management, vaccinations and travel immunizations."

Hmm, screenings, weight management, vaccinations, health education?? Sounds a lot like nursing interventions to me. Would anyone accuse this physician of practicing nursing without a nursing license (as NPs are routinely accused of practicing medicine without a [medical] license)?

If this seems similar to retail health, its because it's clearly lifted from that model: transparent pricing, no appointment necessary, vaccinations - just not episodic care. Oh, but here's where it differs: it is physician-staffed and insurance is not accepted. All the arguments folks make about retail health such as lack of continuity of care, not accepting private insurance (thus driving up health costs) and being profit-driven are missing from this article. It even appears from their website that patients can "obtain prescriptive authority for any ultrasound screening exams" and get any blood test that they choose. My questions are: who is following up on the benign abnormalities often found on these tests. Are they being turfed back to their PCPs? Will this drive up health costs even more?

I am a proponent for anything that attempts to increase access to quality health care. Retail clinics are popular because they are widely accessible, focused in scope, are built on evidenced-based outcomes and most accept health insurance. The same rules need to apply to this hybrid conglomerate as to the retail health model (staffed predominately by NPs & PAs).

"Primary Care," continued

My attempts to start a healthy dialogue regarding NP practice and Dr. Bob's 4/1/08 diatribe have failed:

"One nurse practitioner linked to yesterday’s post and attacked my formulation. At the risk of insulting her and her colleagues, I have worked with nurse practitioners and I believe that she and they overestimate their capabilities. The problem with mid-level providers comes from their lack of training in thinking about complexity. They do very well in routine care, but the big problems in medicine come from incomplete thinking about problems."

Thanks for not insulting me. And oh by the way, I'm not a female.

So much for a prime opportunity to discuss NP education and the like. So much for better understanding the working relationship between NPs and physicians. Oh well, I must return to counting tongue depressors now because that's about as complex as this clinician can get.

Wednesday, April 2, 2008

"Dr. Nurse"

Today's Wall Street Journal Health Blog reports on nursing schools awarding Doctor of Nursing Practice degrees to already advanced practice nurses & nurse practitioners.

This is certainly a hot topic within the nurse practitioner ranks and has stimulated discussions of the pros and cons. Of course, the article is not without the obligatory unsubstantiated and biased medical community comment:

"Also, since these nurses with a doctorate can use “Dr.” some physicians worry that patients could become confused. “Nurses with an advanced degree are not the same as doctors who have been to medical school,” says Roger Moore, incoming president of the American Society of Anesthesiologists."

Some within the medical community seem to think that this is nurses attempt to "fool" patients into thinking we are actually physicians. If the vast majority of us wanted to go to medical school, we would have. We are proud of the fact that we are nurses first and bring a "whole-person" centered approach to patient care rather than only disease-centered care.

Next you will see the barrage of comments that follow on the WSJ Health Blog from all sorts chiming in why they think this is bad for healthcare - then the nurse practitioner bashing will begin. Physicians will cry about low reimbursement rates and if primary care physicians were adequately paid, there wouldn't be a primary care physician shortage. Heck, I'm sure you'll even see retail clinics brought up as they inevitably are. It is a sadly predictable argument.

Nurse practitioners are willing and able to help ease the primary care physician shortage. Rather than work with us to help ease this crisis, some choose to sling mud and maintain the status quo in a severely broken system.

Tuesday, April 1, 2008

"Primary Care"

This is classic. On his blog, DB's Medical Rants, Dr. Bob, writes the following about the term 'primary care' and why it's a poor descriptor:

"When suits, politicians, Wal-Mart and mid-level providers see the phrase primary care, they think “simple care.” They think of patients with one problem, like hypertension or even diabetes. They think of urinary tract infections, sore throats and upper respiratory infections. They think of ear aches and knee pain."

See folks, us lowly "mid-levels" are grouped together with suits, politicians and Wal-Mart executives - quite the grouping! Second, Dr. Bob seems to think that we are incapable of treating anything that's not simple. Apparently, we focus on one thing only. We don't perform screenings, immunizations, mental health evaluations, make appropriate referrals, etc. Please.

Why are you so sour Dr. Bob? Maybe you haven't had the opportunity to work with Nurse Practitioners and/or Physician Assistants and know that as long as they aren't physicians, they must be bad! Maybe you don't know that studies have shown that nurse practitioners render care that is equal to (or better than) physicians. Maybe you could care less. Well, that's why I'm here to help defend the work that nurse practitioners do and maybe, just maybe, open a healthy dialogue to better understand our respective roles.

Monday, March 31, 2008

Invisibility

An article about the lack of physicians in rural upstate New York appears on the Albany Times Union website here, "An unhealthy situation for patients." Sadly, the utilization of nurse practitioners is not mentioned anywhere throughout the article.

Don't get me wrong, yes we need more physicians in rural areas. Though, how innovative would it be to effectively use a resource that already exists, is willing and more than capable of alleviating the health care burden, than nurse practitioners. Lawmakers need to recognize this and support barrier-free nurse practitioner practice along with the offering of similar services as those focused on physicians.

I hate to oversimplify things but according to my crude research: There are 19 physicians licensed in Schoharie county in upstate New York according to statistics from the State Education Department. There are 18 nurse practitioners licensed in the same county. If nurse practitioners were better utilized, the citizens of Schoharie county can essentially have their providers double without any additional resources. Seems like a no-brainer to me.

Sunday, March 30, 2008

Gender Differences Seeking Health Care

Dr. Steven Lamm, author of the book, The Hardness Factor, writes a column on the Today portion of msnbc.com about the different attitudes between men and women seeking health care. Dr. Lamm writes, "After three decades of treating both sexes, I have concluded that many men simply don’t think to put doctor visits on their “to do” lists. They look upon going to a physician as some undesirable form of pampering, no matter how sick they are. In general, men are not all that good at taking care of their health, probably because they have not grown up with periodic medical exams. "

There is no doubt that women seek health care earlier and more often then men. As a former college health provider, I would easily see 4 female patients to every 1 male patient. While Dr. Lamm attributes this difference to the "traditional masculine pattern," to which I largely agree, I have additional food for thought. Perhaps men aren't encouraged enough to bring up their concerns or when they do, they are minimized by their male providers. According to gender statistics from a 2006 AMA survey, there are roughly 665,000 male physicians to 256,000 female physicians. Could this "traditional masculine pattern" carryover to the provider side too?

I think the take home for providers is that we be more cognizant (other than the obvious) gender differences between men and women seeking care. The take home for patients, male or female, is that if your provider isn't adequately assessing your needs and concerns, don't be afraid to ask or seek another opinion.

Friday, March 28, 2008

Nurse Practitioner Study On Nasal Rinsing

Nurse Practitioner Jennifer Walsh recently conducted a preliminary study along with Dr. Wellington Tichenor on a bacteria found in tap water that may be linked to chronic sinusitis (a sinus infection generally considered to persist for 3 months or more). Their findings suggest a bacteria, atypical mycobacterium, found in tap water and not killed by chlorine, can be a contributing factor to chronic sinusitis when patients use tap water for nasal irrigation. Patients with sinus infections are often told to irrigate the nasal passages, and thus the sinuses, with a mixture of salt and tap water to assist in clearing secretions and congestion. Though more research is needed to further investigate this claim, perhaps we should suggest using a store-bought sterile preparation of saline in the interim.

You can view the short piece by WABC 7 here and the link to Dr. Tichenor's website here. Congratulations Nurse Practitioner Walsh on your research!

Nurse Practitioners Fill Key Roll

Here is a well written article from today's Tennessean about Nurse Practitioners filling key rolls in primary care. To no one's surprise, The Tennessee Medical Association opposes this and even wants to add more barriers to nurse practitioner practice and therefore block access to affordable, high-quality care. They even find a way to throw retail clinics in the mix.


My question is why do they feel a need to impose stricter limits on NP practice? Are there studies to show that NP-practice is unsafe or not as good as physician-practice? In fact, studies show the contrary. I like to think of myself as a person of proof. If you can show me other than anecdotal evidence, that NP practice needs limits rather than autonomy, I'd welcome the proof.


I also don't want this to be a nurse practitioner vs. physician rant. We are all members of the healthcare team and need each other to collaborate and critically think when caring for patients. I certainly can't do it all by myself nor do I really want to. In my experience, I've see physicians collaborate with one another, pharmacists, physical therapists and yes, even nurses. A lot of us have areas of special interests or expertise. Wouldn't it be better to collaborate with that individual on that particular topic rather than someone not versed in that area? That would seem to make sense to me!

Wednesday, March 26, 2008

Hello & Welcome

Welcome to my blog! I've pondered creating this for sometime now as I've searched the Web along with other blogs for current nurse practitioner-related content and have been unable to find much. This is my attempt to provide accurate and current information regarding Nurse Practitioner practice.

My main goal is to start a healthy dialogue among nurse practitioners, other healthcare professionals and patients alike. There are a lot of misconceptions, inaccuracies and feelings about what nurse practitioners can/can't and should/shouldn't do. I've come across dozens of blog posts that are just plain wrong and hedge on bashing the profession. I hope to clarify some of these misconceptions in the hopes of providing the best barrier-free care possible to patients alongside other members of the healthcare team.

For those of you unfamiliar with a Nurse Practitioner, lets start with a definition from the American College of Nurse Practitioners:

"Nurse practitioners (NPs) are registered nurses who are prepared, through advanced education and clinical training, to provide a wide range of preventive and acute health care services to individuals of all ages. NPs complete graduate-level education preparation that leads to a master’s degree. NPs take health histories and provide complete physical examinations; diagnose and treat many common acute and chronic problems; interpret laboratory results and X-rays; prescribe and manage medications and other therapies; provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed.

NPs are authorized to practice across the nation and have prescriptive privileges, of varying degrees, in 49 states. The most recent Health Resources and Services Administration Sample Survey report (2004) shows 141,209 Nurse Practitioners in the United States, an increase of more than 27 percent over 2000 data. The actual number of nurse practitioners in 2006 is estimated to be at least 145,000."

Thanks for reading, please write comments and check back often. I hope to post regularly.