A Nurse Practitioner's View

A NY Times article refers to a new study from the BMJ involving the prescribing of placebos to patients. Many ethical dilemmas are raised with this practice. The "placebos" referred to in this study weren't placebos at all, they were either vitamins or different classes of pain management medications. Wiki defines Placebo as: ... a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity. Any therapeutic effect is thought to be based on the power of suggestion . The word placebo is Latin for I will please. Prescribing placebos is only part of the game. There is also the ordering of expensive lab work and diagnostic tests that go hand in hand with the powers of suggestion. I try to be mindful of the tests that I order and explain the risks and benefits of such tests/treatments. Sure, there have been times when I've contemplated creating my own "S- Pak " in the hopes of creating a magic treatment. But ...

On October 24, NOW on PBS will explore a projected nursing shortage that could impact quality of and access to care for millions of patients. Be sure to tune in! Below is the press release: Show will highlight Innovative solutions in New York City and elsewhere NEW YORK, September 26 – A U.S. government study projects that by the year 2020, there will be a nationwide shortage of up to one million professional nurses . The nursing shortage is already placing strains on the entire medical system. On October 24, 2008, the Emmy Award-winning newsmagazine NOW on PBS will examine the root causes of this crisis, and innovative efforts to reverse the trend. Even though qualified nurses are in high demand and hospitals are offering attractive incentives, many are leaving the profession. Even more alarming: few are choosing to teach the next generation of professionals. As a result, tens of thousands of applicants are being turned away from the nation's nursing schools. The production is sup...

A New Jersey jury recently awarded $400,000 to a deaf patient because her physician refused to provide a sign language interpreter throughout their visits. The patient ultimately switched physicians since the steroids she was receiving caused facial edema. The new rheumatologist subsequently took her off steroids and was able to explain that the edema was a side effect of the steroids and not from her illness. This case presents many ethical dilemmas for the practicing clinician. I have seen other blog posts related to this case. The knee-jerk reaction talks about moral obligations and financial implications for the physician to hire an interpreter that would result in a net loss for the visits (the visits were reimbursed at $49 and the interpreter would cost about $150-200/hr). Those angles miss the point. Where is the culturally competent care? Cultural Competence is defined as: (via wiki) ... an ability to interact effectively with people of different cultures. Cultural competenc...

Here is an article about a drive through flu shot clinic in Pennsylvania. The service is targeted at Seniors and health officials devised a system regarding which lane you drive up to and other logistics regarding the vaccination. At first, I thought it was another gimmick. However the more that I thought about it, it does make sense. I've had a few requests over the years to vaccinate seniors in the drive-by fashion. This always put me in a difficult situation -- not because of the actual injection -- but what happens if there is a reaction and how can I ensure that they wait the recommended 20 minutes post vaccination without driving off into the sunset? From a public health perspective, it makes complete sense. High-risk patients should get the immunizations and we must examine new ways to make this happen. We certainly can't visit them all in their homes. As long as there is a well-thought out system with policies and procedures in place, ideas such as this will prompt us ...

Here is a great post from a medical student about retail clinics. Here is someone who clearly understands the need the clinics are filling and more importantly (in my opinion), how nurse practitioners are part of that solution. It's good to see such an un -jaded perspective and how we can all work together in today's complex health system.

Today's WSJ Health Blog writes about the infection, Clostridium difficile (C. diff), and how it's becoming known as the 'new' MRSA . The blog writes: The dark irony is that, because C. diff typically kept in check by the healthy bacteria that live in the digestive tract, people often get C. diff infections after treatment with antibiotics (which kill both harmful and healthy bacteria). It amazes me to this day, how many people come into the office demanding antibiotics for what are mostly viral infections (which of course, antibiotics do not help). I hear the same stories from my colleagues. Usually, once the side effects are rationalized, most people understand the consequences and we decide that antibiotics aren't indicated for this illness. Of course, this approach takes time and unfortunately, it's much easier to write the script for the antibiotic and not have to take more time out of one's busy schedule to explain this. Just as unfortunate, is that ...

On Friday night, September 5 th , the three major networks aired the telethon, Stand Up To Cancer . It is estimated that they raised over $100 million dollars which according to their website: ...will support research projects conducted by interdisciplinary, multi-institutional translational and clinical research "Dream Teams" and high-risk Innovative Research Grants from which ideas for new Dream Teams may arise. The funds will be administered through the American Association for Cancer Research ( AACR ) , the largest scientific organization in the world focusing on every aspect of high-quality, innovative cancer research. This is an amazing cause and could've even had a larger impact had it been on more networks and if it aired on a night other than Friday. The show featured patients battling cancer as well as celebrities and their cancer stories. The show followed actress Dana Delany for her annual breast exam. I was stunned and pleasantly surprised to see the exam p...

Politico.com reports on a new Obama ad that uses a Planned Parenthood nurse practitioner narrator. The ad happens to be about the pro-choice vs. pro-life debate. The nurse practitioner says: "“Let me tell you: If Roe vs. Wade is overturned, the lives and health of women will be put at risk. That's why this election is so important,” says the nurse-practitioner who narrates Obama’s ad. “John McCain's out of touch with women today. McCain wants to take away our right to choose. That's what women need to understand. That's how high the stakes are.”" While my intention is not to turn my blog into a political forum, this certainly is a poignant event for nurse practitioners - to be featured in the national spotlight by the Democratic Presidential Candidate of the United States. It is, however, on a polarizing topic that may further shape individuals views of nurse practitioners either positive or negative. I have been unable to hear the ad for myself so if anyone ...

As nurse practitioner-staffed retail clinics continue to open and expand (despite what many recent reports say otherwise), they continue to fall victim to physician-centric comments undermining the competence and professionalism of other health care providers. Am I surprised? Not at all. It has all come to be so routine now. Take for example, a recent article written in the Topeka Capital Journal . The end of the article quotes a pediatrician's take (by the way, the American Academy of Pediatrics opposes the use of retail clinics - whatever that means) on why one shouldn't use retail clinics. The article goes on to say: As for people who don't have insurance, Cain said there is always a place for them. "We have plenty of places for people to get care," Cain said. When looking for a physician, Cain advised finding someone who has flexible hours and cares about patients. "I would find a doctor who can provide you with a good medical home," she said. ...

An article about physician assistants and nurse practitioners appears in the NY Times Jobs section. The article does a very good job of explaining both professions though I would disagree with a few of the statements. Another important difference is that P.A.’s are generalists, while nurse practitioners train in a specialty like family medicine or women’s health. As a result, P.A.’s can switch fields more easily . - I would say that isn't necessarily true. Since the majority of NPs are trained in family health, I think it's just as easy for these FNPs to transition into different roles. To patients, the two roles can seem very similar. Salaries can be similar, too. The average total income for physician assistants in full-time clinical practice is about $86,000, according to the P.A. academy. The average total income for nurse practitioners is $92,000. - average salary of $92k? I think that sounds pretty high. Most of the NPs that I know are in the $70 - $90k range and I ...

Today's New York Times has an article about the Medical Home concept. These projects are becoming more popular as insurers are deciding to cover the costs. The article refers to a patient who visited his very busy physician that missed a stroke diagnosis because of a hurried exam. While mostly inexcusable, it provides a real life example of the issues occurring every single day due to the system's lack of access, communication, reimbursement, and high-quality. While the article doesn't make specific reference to NPs , Senators from New Mexico, Iowa, Alaska and Maine recently discussed expansion of Medical Home projects to include NPs , and other non-physician providers of primary care to lead medical home demonstrations. Senator Bingamin of New Mexico sums it by saying: Furthermore, nurse practitioners epitomize the delivery of high quality, cost-effective primary care that is crucial to the medical homes model. Senator Murkowski of Alaska adds: Nurse practitioners funct...

Medgadget recently had the opportunity to interview the president-elect of the AMA, a cardiologist. Someone obviously with the finger on the pulse of primary care. One of the hot topics that he was asked about was the bleak outlook on primary care. This is from the interview: Q: Here's a question from one of our editors, Nick Genes. He's a resident of emergency medicine at Mount Sinai in New York. Many pundits and experts believe that the US government will improve access to primary care (one way or another) in the next 2-5 years. The Massachusetts experiment suggests there will not be enough primary care doctors to cover the increased demand. Already, primary care doctors are overworked and under compensated, with many leaving the field or choosing specialty training instead. How is the AMA planning to respond to this challenge? A: ... We continue to mention the importance of trained primary care, and I should also mention the AMA created the scope of practice partnership, b...

Picture this: hundreds of patients braving the elements, lining up for access to a free healthcare clinic, dozens of healthcare professional volunteers offering their time to provide medical, dental and vision services and thousands of dollars in donated medical supplies. Sound like a medical corps serving a third world country? Guess again. Its happening in Tennessee, Virginia and Kentucky. Tonight, 60 Minutes ran an updated story about Remote Area Medical (RAM) . This is an amazing volunteer organization started by Stan Brock. His original intention was to help injured and sick people in desolate parts of the world. Now, a large part of the people being helped are right in our own backyard. What does that say about the state of healthcare today? The news piece also highlights NP volunteer Teresa Gardner providing women's health services to those in need. She counsels and treats a patient that hasn't followed up in 3 years status post cervical cancer surgery. Sadly, these s...

Hi All, I will be on vacation for the next week! So, I won't be posting. I know I know for all of the few readers out there you'll just have to find another way to spend your time! :-) In the meantime, here is a nice press release from the AANP regarding their recent conference that was attended by more than 3000 NPs. Stephen (Image via flickr)

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...