A Nurse Practitioner's View

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 sig...

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!

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.

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 ...

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 doe...

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 dy...

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.

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 th...

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...

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.

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...

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 1...

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.

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.

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 w...

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 ...

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.

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 .")

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.

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 physici...