Monday, June 17, 2013

Response to WSJ Article, "Should Nurse Practitioners Be Able to Treat Patients Without Physician Oversight?"

This post was written in response to the WSJs article, "Should Nurse Practitioners Be Able to Treat Patients Without Physician Oversight?"

As much as some would like you to believe that this is not about turf protection, make no mistake, it is exactly about protectionism and nothing in the interest of the patient. The latest buzz words are now “team-based care” where nurse practitioners, physicians, and other members of the health care team, are working for the common goal of better health outcomes while the inefficiencies of today’s healthcare system vanish. The problem with this presumption is that there is no defined model of team-based care.

So what then is team-based care? If you ask a physician what team-based care is, they would say it is where they are in charge of the team and tell what the other members to do. They hold the most hours of in-patient training and in doing so can care for every patient and every condition without anyone else telling them how to do it. Plain and simple. Captain of the ship.

If you ask a nurse practitioner about team-based care, they will refer to a theoretical model where all members of the team are active participants in the provision of care for that patient. True collaboration takes place where providers seek solutions collectively and the right provider is caring for the patient at the right time and place. Precious time is spent developing the communication strategies of the team, the team composition and conflict resolution.

To simply state that the “…University of Missouri Department of Family and Community Medicine conducted a recent study of all comparative research on the topic and concluded ‘substitution of physicians by independent nurses providing comprehensive primary care is not an approach supported by the literature’” is disingenuous at best. First, this purported study simply used the data from an established systematic review published by the Cochrane Library of Systematic Reviews – “Substitution of doctors by nurses in primary care” by Laurant et al. (http://webcache.googleusercontent.com/search?q=cache:Ffm3TsFaMgQJ:www.aafp.org/online/etc/medialib/aafp_org/documents/about/congress/2010/res605background.Par.0001.File.tmp/SubstitutionofPhysiciansbyNursesinPrimaryCare2011.pdf+&cd=1&hl=en&ct=clnk&gl=us). Because the American Academy of Family Physicians (AAFP) didn’t like the outcome of the peer-review process, they decided to fund a second review and essentially re-write the results so that it favored a fictitious outcome, thereby minimizing the contribution of NPs. To date, their “new” study has yet to be published in any peer-reviewed journal that I am aware of.

The next talking point is to highlight how NPs order more tests. There was one small study that observed this (well over 10 years ago), however the study did not focus on patient outcomes. Therefore, this has very little applicability to draw any significant conclusions about healthcare costs or anything else for that matter. 

Finally, nurse practitioners do not want to be physicians nor do we purport to be. NPs are not taking a “shortcut” to medicine or trying to fool patients into thinking we are something we are not. It is our goal to be recognized for the unique clinicians that we are – melding nursing and medicine together to care for the whole patient. Nurse practitioners are among the majority of providers caring for the health disparate and doing so in an evidence based, culturally competent, and high quality manner that NPs bring to every patient encounter. The pillars of health promotion, health education, wellness, and disease management make nurse practitioners uniquely qualified for the aging population. And when there is a patient with multiple health issues whose body and/or mind are not responding to the latest recognized treatment, it’s good to know that a physician is waiting for the handoff. Or are they? 




1 comment:

Anonymous said...

Stephen, Absolutely. I can speak from personal experience - at my last hospitalization the ED PHYSICIAN ordered 5% glucose IV for me - an insulin dependent diabetic when I was transferred to inpatient status! It was the NP who saw me on the floor who changed that order to normal saline. My complaints to hospital staff went unheeded and it was not until the NP saw me that the change was ordered. So much for the claim that it is the MD who makes all the correct decisions! Really, MD does not stand for Major Diety and infallibility is not conferred by a medical degree.