Tuesday, April 20, 2010

Reflections

With the recent increased media attention regarding nurse practitioner practice, I've noticed many inconsistencies and misconceptions in the media. Here are some of my own clarifying points:

  • Nurse Practitioner practice is not brand new. The profession has been around since the mid 1960's. Therefore, all of these intimations that we are doing something (or looking to do something) new is inaccurate. There is a 40-year history of NP practice.
  • NPs are not individuals who one day arbitrarily started writing prescriptions. There is a standardized education, training, licensure, and certification process that allows us to perform in that capacity. There are differences in each State practice act that sets the standard for what we can (and can't) do in each state. Note that the majority of State acts have these regulations that haven't been updated to reflect current education and training.
  • The Doctor of Nursing Practice (DNP) degree is often linked to these conversations but this is really a separate issue. Yes, this is a relatively new terminal clinical degree for the profession. There used to be to be the Doctor of Nursing Science (DNS) that has pretty much fallen out of favor to the DNP. Why in the world would this be a bad thing? (Oh right, because we are trying to confuse everyone into thinking we are really a "doctor" which I guess is some how synonymous only with a "physician" these days.) Now, this educational degree in and of itself does not change existing practice. There are many opinions about the DNP degree out there (of which I will share mine soon) but the bottom line is that the degree does not change the requirements of current state licensure/certification and to the already existing 140,000+ NPs.
  • Our approach to patient care is not the allopathic model. We utilize a synthesis of both nursing and medical knowledge to care for patients. I as an NP, generally feel that lifestyle modifications, health education and communication, disease prevention/treatment, wellness preservation and a partnership approach are driving principles of my philosophy to practice. NP education has largely adopted the evidence-based practice (EBP) model of care. That is, using proven interventions in the provision of care rather than doing something the way it's been done forever. Does this allow us to spend more time with patients? Perhaps. But maybe the evidence suggests that spending more time with patients produces better outcomes.
  • NPs face the same reimbursement issues that primary care physicians face (albeit at an even more reduced rate - Medicare reimburses NPs at 85%) yet the majority of NPs choose primary care or closely related field to work in. This, of course, assumes that every NP wants to own their own practice. I will go out on a limb and say that most want no part of this. The push for autonomous practice stems from out-dated and arbitrary barriers that negatively affect patient care. For example, the NP working for a physician in Florida with no intention of starting their own practice but with their own panel of established patients. The NP sees one of their patients determines that the patient needs some pharmacological pain medication intervention yet cannot prescribe this to their patient since there is no physician in the office that day (Florida NPs cannot prescribe controlled substances). The patient is ultimately out of luck here and suffers since they cannot have their pain managed. It also puts the NP at an unfair disadvantage since patients knowing this regulatory issue may choose another provider based on this.
  • NPs are filling a void in primary, not "taking over." I've said time and time again in this blog, let the patients decide if they want care from an NP. If not, we would surely have little to argue against. However, if patients want to choose care from an NP, they should be able to without prejudice or barrier.
I continue to have tremendous respect for my physician colleagues. I appreciate their time commitment to the education/training process and vast knowledge base. I cannot perform surgery or many other procedures nor would ever want to. But I am confident in identifying when a patient does need surgery for example. I just don't necessarily think that physicians can be the only providers and captains of health care. I don't buy into the argument that we don't know what we don't know. We all collaborate and refer to colleagues when something falls outside of our comfort zone or specialty. The one who thinks they know it all and can cure all is the one I would be especially leery of.

5 comments:

Yusharn said...

Hey I'm a FNP student and I agree with what you had to say in this blog well said. Now another issue is, male nurse practitioners are nursing is still a female dominated profession. We must break barriers and tell the public that men can be nurses and nurse practitioners as well and not only physicians.

jss said...

Wow, Stephen VERY well said! You really captured the issues!

Anonymous said...

All mainstream health providers are trained in evidence based practice, especially physicians. It is certainly not exclusive to NPs, as your post suggests.

Furthermore, all captains need ships. The law profession has paralegals and court reporters and law librarians, but lawyers rule the roost. It has to be the same way in medicine and physicians are the obvious choice.

Stephen Ferrara, NP said...

Nurse practitioners have championed the evidence-based practice movement. I would hardly say that "all mainstream health providers" are trained. When you talk about systematic reviews and PICO questions, people's eyes start glazing over.

The issue is that medicine is only one aspect of HEALTH CARE. You can rule your roost in medicine. Unfortunately, that isn't going to get people very far when many issues fall outside your roost.

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