Monday, June 30, 2008


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

Main Entry: col·lab·o·rate
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 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


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.