A Nurse Practitioner's View

With the passing of the recent historic health insurance reform, the focus has turned (see here and here and here ) to how will the system deal with the influx of approximately 31 million newly insured seeking access to care. All of these articles address the current shortage of primary care physicians in some way and creates a sense of urgency for patients to try and secure one before access becomes crippled (as it has in Massachusetts). What these articles fail to address is the true potential that NPs and PAs have to pick up this slack. There is this incorrect assumption that NPs, facing the same barriers in primary care, are flocking to lucrative specialties. Fortunately for patients, this is not the case. A recent survey by Advance for Nurse Practitioners, reveals that most of the NPs polled work in predominantly primary care or primary care-type settings. Also a very informal survey of the NPs that I know has a similar result. So what does all this mean? The good news is that ...

There are so many unknowns regarding both patients and providers with the passing of the recent monumental health care legislation. Thanks to a recent post on AJN's Off the Charts blog, they posted a link to a handy ANA chart comparing both versions of the legislation and what it means for nurses and nurse practitioners. Of course, this is subject to change somewhat based on the revisions that still need passing however, I would imagine that it will remain pretty close to this. It appears the biggest factor for NPs is the ability to lead the team of providers in Patient Centered Medical Home demonstration projects. Stay tuned for more on this white hot topic of reform......

The US Department of Health and Human Services just released " Initial Findings from the 2008 National Sample Survey of Registered Nurses ." There is some valuable and interesting information in the latest report (the last one was done in 2004). Of note: There were an estimated 3,063,163 living in the US as of March 2008 (of these, 2,596,599 were employed in nursing positions). The average age for all licensed nurses rose from 46.8 to 47 years and employed nurses rose from 45.4 to 45.5. There are 158, 348 identified NPs The number of NPs grew 12.1% over the last 4 years There were an estimated 28,369 RNs with a doctoral degree in 2008. This is an increase of 64.4% since 2000. The workforce is becoming more diverse. 6.6% of nurses are male (a small jump from 5.8%) but a higher percentage of recent graduates were male from previous (4.1 % prior to 1990 vs. 9.6% since 1990). Hispanics are the most rapidly growing group of registered nurses. These are just a few highlights fr...

I have tried to refrain from taking the bait from some recent negative opinions regarding nurse practitioner delivered care. Quite frankly, the arguments are old and tired. My goal as a clinician is to deliver the highest quality, evidence-based, and culturally competent care that I am capable of. I refuse to pit NPs versus other professions. We all have our own slightly varied philosophies and approaches to delivering care. Some may prefer the approach of a DO while some choose to see a NP or PA or MD. I believe patients have that right. However, I cannot believe the nonsense and out of context rubbish posted on the AMA's "Virtual Mentor" in a column entitled, " The Primary Care Shortage, Nurse Practitioners, and the Patient-Centered Medical Home. " Oh, where to begin! The opinion piece begins with the patronizing idea that NPs are part of the solution but not THE solution to the primary care crisis in this country. Funny, but I couldn't find a single ref...

The NY Times reports that the F.D.A. is cracking down on food manufacturer's health claims on their package labels. I have somewhat mixed feelings on this. On the one hand, if a purported health claim is enough to convince someone to make wiser eating habits, then that has to be a benefit (albeit to the financial advantage of the manufacturer). However, as we strive to incorporate scientific evidence into these health claims, they need to be accurate and actually based on good data. A lot of supplements and vitamins now shy away from clear health claims for fear of the same F.D.A.-type crackdown (though is simply adding the word, " may " to the claim enough? As in "Vitamin C may contribute to increased immunity," etc.) It seems as if the F.D.A. is willing to work with the manufacturers to convey accurate and scientific information that should satisfy the manufacturers while protecting and correctly informing consumers and this should be lauded.

Today, the University of Wisconsin and Robert Wood Johnson Foundation launched www.countyhealthrankings.org , a website that examines the health of each county in the United States and ranks them accordingly. This is a wonderful resource for both patients and health providers that examines health at the local community level. Health disparities exist here in our own country. This new comprehensive database is an evidence based perspective so we can begin to address these issues. All key stakeholders must be engaged if we are going to make a difference. Where does your county rank and how will you address these disparities? (image borrowed from: http://www.msnbc.msn.com/id/35439793/ )

Today, Michelle Obama launched the Let's Move ! campaign to tackle childhood obesity. The goal of the program is: "to solve the epidemic of childhood obesity within a generation." We are right there with you to tackle this challenge! Speaking of obesity..... William Neuman of the New York Times takes on our antiquated and hard to interpret food labels in terms of serving sizes. Its a great video and shows what a serving size should be according to the label. Now, the FDA is considering changing the standard serving sizes and encouraging manufacturers to list calorie counts on the front of packages. It is truly mind boggling to try and interpret portion sizes and nutrition information on today's foods. Most of us under-estimate the amount of food we eat. Healthy living begins with our diet and if we cannot adequately determine the nutritional value of what we are consuming, it becomes impossible. This also ties into the recent study that showed calorie counts are f...

Thank you to New York Senator Montgomery of Kings County for introducing legislation that will allow nurse practitioners to sign death certificates ( S.2969 ). The bill passed the NY State Senate with strong bi-partisan support, 58-3. It must next pass the Assembly and then on to the Governor's desk for approval to become law. Here is some additional information on the bill and its rationale.

I am a techno geek. I love my iPhone and BlackBerry . I have a laptop, a netbook and a couple of desktop computers. I am currently piloting a Kindle DX , which is pretty cool. Today, Apple introduced the iPad , their hotly anticipated tablet computer. It is a beautiful device, about the same size as the Kindle DX , though basically a blown up iTouch . While I can't wait to get my hands on one (it's not available for another 60 days or so), I wonder what apps will be developed to enhance the flow of information in health care. There are already a number of EHRs that run on mobile platforms and since this basically uses the iPhone operating system, it would appear that this is tailor made for health applications - both on the patient side and on the clinician side. This device may aid in the modernization of health records. The flow and integration of data can and should be so much better. I believe this is a game changer and we will see a further explosion of health related a...

I came across this wonderful post on Dr. Edwin Leap's blog, " Attention Doctors: People may not like you. " It is relevant for all clinicians and talks about the interactions between patients and providers, patient expectations, and the handling of these expectations. The important thing to remember is that we are providing a service to our patients. Patients come to us for our advice, opinion and to make them feel better. Some may not agree with our plan and will seek further opinion - and sometimes they certainly should. Patient's should be empowered to be actively involved in the decision making process. But oftentimes silos are created, further fragmenting care and communication. That's why I believe firmly that comprehensive care is best delivered in teams - where team members share the same focus and are aware of each other's strengths and weaknesses. There are so many patient variables to consider: culture, socio -economic status, gender, past medical...

An article appears in Health Magazine advising its readers " when its OK to skip the Doc ." But of course in doing so, nurse practitioners get slapped. You see, the article refers to convenient care clinics - a continually hot topic - and how their nurse practitioner staffed model makes it OK for them to treat minor boo-boos but aren't capable of treating more serious maladies. Now in all fairness, most clinics aren't currently designed to treat conditions beyond episodic-type care and health screenings though there are reports that say this trend may be slowly changing to include other conditions. I just don't understand why the inference is always that the NPs staffing them are limited to treating just those conditions as well. I know plenty of instances where NPs referred patients to other providers based on subtle signs picked up during a convenient care visit which might've otherwise gone unnoticed. Further, patients in these settings were easily abl...

Just when you think you might've seen it all, some companies are rolling out medical gift cards . There is perhaps nothing more complicated as a health care consumer attempting to navigate the health care system and trying to figure out costs. I can see it now: bewildered looks from health office personnel trying to decode what the card even is in the first place; "should we apply this towards your deductible, or maybe the lab fees" etc. Of course, the problem is most of the time folks have no idea what they are paying for health care services and providers don't know what they are getting reimbursed. Here is just another poor attempt at trying to solve the mess of the health care system we have today. At least with a Health Savings Account ( HSA ) you get a break with it being tax-exempt. I'm not sure what benefit these medical gift cards offer. Maybe since costs are so out of control, people would rather not carry around the wads of cash to pay for services? So...

Hi All, It has been awhile since I've last had a thoughtful blog post (a hectic personal life has a way of re-prioritizing things!) Though there's been no shortage of topics to write about. The heath care reform bill has gained momentum, mammogram screening guidelines were revised , and H1N1 vaccine and cases continue to make headlines. This is certainly an interesting time to be in health care. I look forward to seeing what the future brings and plan to be part of these discussions (or at least have something to say about them here on my blog). Till then......

Happy NP Week to all of my NP colleagues out there! If you are a patient of an NP or work with one, be sure to recognize the fine work they do every day. Here is the press release from the American Academy of Nurse Practitioners and the theme this year is 125,000 Solutions to the Primary Care Shortage. (I'm a bit late, but also Happy PA Week to all of my physician assistant colleagues).

I came across this well thought out commercial that has appeared on TV from the U.S. Department of Human Health & Services' Agency for Healthcare Research & Quality ( AHRQ ). Their website has a few other public service announcement-type of ads. With their, "Questions are the Answer" campaign, they are encouraging patients to ask questions about their care and to take an active role in the provision of their care. Hopefully, patients and providers alike will embrace this idea so that there are more answers than questions. Any questions?

With all the talk about H1N1 influenza, I think it;s important for folks to understand where the H1 and N1 come from. The "H" comes from the substance hemagglutinin and the "N" comes from neuraminidase . There have been identified influenza strains of the H and N types and this is how some influenza viruses are classified. The particular "swine" flu that has garnered so much attention is of the H1N1 type. A few years ago, the fear was of the avian type, H5N1. This past Spring, the Wall Street Journal Health Blog did a good job explaining some of the background regarding the naming of this particular strain of influenza. This may help us all understand the nomenclature and rationale behind what has become household names.

I recently decided to obtain auto insurance quotes from most of the major insurance companies websites. The quote process is generally very simple: enter your information and you get an instant on-line quote. As I feel it necessary to perform some due diligence and not just go with the least expensive quote, I Googled "auto insurance ratings." Well, what a frustrating experience. I wouldn't say that I am now more confused - only that it wasn't at all helpful. The Web is filled with a smattering of reviews and many of the negative ones seem that there is more to the story than what is written. In addition, we mostly know that an unsatisfied customer is much more likely to take their story to the Internet and post it as opposed to a satisfied customer with no issues. What's my point to this post? I have come across various articles and websites that give patients the opportunity to rate their health care provider. In fact, here is an example of such a site. One can...

The New York State Department of Health recently passed emergency regulations requiring all healthcare personnel working in hospital and nursing homes to receive mandatory influenza vaccinations or face termination of employment. I am a vaccine advocate and believe that vaccinations have decreased and in some cases eradicated some infectious illnesses. I do, however, worry about the mandate aspect of this law and how it will be truly be enforced. What do you think? Good idea? Cutting-edge? Violation of privacy? I'd love to hear your thoughts.

Pennsylvania Governor Ed Rendell , a longtime champion of NP practice writes a column in today's USA Today, " Health reform can count on nurses ." I am encouraged by this support and recognition for the thousands upon thousands of NPs , Nurse Midwives, Nurse Anesthetists, and Physician Assistants practicing and caring for patients in community, hospital and out-patient settings every day. We are not a new concept nor fad. Our practice is centered on our patients. I invite everyone to read the blogs on my NP Blogroll . You will find examples of the extreme care and commitment we give to our patients. It certainly seems as if Governor Rendell is reading. Its exciting to ponder who else may be reading as well.......

It's back to school time and that means droves of physical forms flowing into offices as a requirement for school. Each form is different in its length, complexity and readability. Some practices have refused to complete forms and will attach a copy of their own. Some practices charge an additional fee to have the forms completed. Why can't we ascribe to a standardized school form that everyone can use? I have seen some forms ask only for height, weight blood pressure and immunization history while others require a complete review of systems, physical exam, diagnosis, and dietary restrictions. What do you think? Should we have a standardized physical form? Do you charge extra for completing patient's forms? If you are a parent or a patient, what do you think of this superfluous and redundant paperwork? I'd love to hear your thoughts.