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


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.

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.