With a burgeoning population speaking English as a second language seeking health care in our complex system, the need for competence, clarity and transparency in treatment is more important than ever. In this issue, we explore how the system is changing and whether these changes are the right prescription for those in most need of assistance.
The age of the singular general practitioner is quickly coming to an end. For better or worse seeing a doctor these days means seeing a medical group, not an individual physician. The more the merrier, right? Not necessarily. Older patients and the growing demographic of those who speak English as a second language are particularly reliant on a monogamous personal relationship with their doctor. And the blurring of lines between MDs (medical doctors), DOs (doctor of osteopathy) and NPs (nurse practitioners), as well as the alphabet soup of degrees granted to a growing and diverse class of medical providers threatens to erode that special trust and relationship. When is a doctor not a doctor? When the doctor is a nurse.
The movement to expand the scope of practice for nursing isn’t some sinister plot to dumb down medical care or diminish the need for medical doctors. It’s a practical dollars and sense matter. An argument for broader nursing scope of practice options point to the high cost of a medical degree and the need to get into specialties with higher income potential to pay off student loans to a dramatic decrease in primary care physicians and a need for more NPs. And as Brad Wright explains in “The NP vs MD Debate Is Missing the Bigger Picture” for MEDPAGE, the shortage of primary physicians is worse when minority graduates are separated and counted. And it doesn’t get much better when you factor in the number of minority NPs. “In fact, 2012 residency matching rates not only show continued unfilled positions in primary care, but that the rates of graduating minorities are highly skewed from programs. This contributes to even greater problems with finding primary care providers that reflect the populations they serve. Sadly, this is also true for nurse practitioners, where only 4.9 percent are African-American, 3.7 percent are Asian or Pacific Islander and 2 percent are Hispanic.”
Having said that, the relationship between patients and doctors is a complicated and intimate one and can’t be easily dismissed. It requires a true and unbreakable connection steeped in trust and an understanding from patients’ point of view that these are professionals who are completely in sync with their needs and like a modern-day Sherlock Holmes knows them so well that they can diagnose and treat maladies that medical tests alone can’t reveal. So, no, the more is not the merrier.
Those wary of the expanded scope of practice worry about the potential lack of transparency in patient care. Transparency, especially with ESL patients and the older patient population, is particularly important. That’s what made my recent trip to my family physician so disappointing. I was there to be cleared for an upcoming surgery. When I arrived, I found this usually small and quiet office buzzing with activity. My trusted family physician had hooked up with a medical group without notice. The inner office area was awash with at least a dozen twenty-something office workers in blue and green scrub-type uniforms scurrying around looking very busy. The waiting room was packed with impatient patients waiting to be called in for their appointment. Most were confused and anxious. One by one they asked to see their regular doctor. They were told he was not available. They persisted in Italian, Spanish and English, asking that they be given information about when he would be available. They would come back then. Their questions were not directly answered. Instead, these office workers evaded and avoided. They were told they needed to see “Doctor” Marsha*, instead. “Doctor” Marsha would take care of them now. The anger and frustration and dread started to boil over now. They needed the professional personalized care they had come to expect from a doctor who knew them better than some of their own family members. Now they were being asked to see a mysterious “Doctor” Marsha, a stranger.
In the sea of blue and green clad animated staff members, I would catch a brief glimpse of a white-coated woman with a stethoscope flitting in and out of treatment rooms. After a two hour wait, I was more than a little curious about “Doctor” Marsha. When she finally appeared, she introduced herself as simply “Marsha,” not “Doctor” Marsha. And as it turned out she couldn’t clear me for surgery. She said it was because she was just filling in for the DO who had the day off. He would check over her notes and get back to me about my clearance. That was not entirely true. I checked into “Doctor” Marsha’s credentials. She wasn’t a doctor at all, she was a nurse. In fairness, although the entire staff referred to her as doctor, she was honest enough to call herself simply Marsha. But I am convinced that the older and ESL patients that shared the waiting room with me had no idea that they were putting their lives in the hands of a nurse, however advanced in her training, and not a medical doctor. They saw a white coat and drew the conclusion that this office wanted them to reach. This scene is being repeated in health care offices across America marginalizing a population already feeling isolated and outside the mainstream of this majority white English-speaking and youth-oriented society.
However, if the worse that can happen to patients is confusion and anxiety, the tradeoff is a stop gap way to close the growing gap in primary care, which is leaving more than 60 million without adequate access to basic medical care, particularly in rural America. The most ideal situation is to create an environment where medical caregivers are clearly defined, stay in their lane and work together as a team to provide the best and most efficient care for all. However, ideal is not always practical or possible.
There are many reasons and incentives for nurses to pursue advance degree. Many states allow certain trained nurses to open private practices, but at what cost to health care and medical transparency? These are the questions raised in an article we are sharing in this issue by Dr. Niran Al-Agba, MD for thehealthblog.com. entitled “MD vs, DNP: Why 20,000 Hours of Training and Experience Matters.” Her concern is the danger of misrepresentation amid a wave of legislation to expand nursing roles. “As southern states entertain legislation granting nurse practitioners independent practice rights, there are some finer details which deserve careful deliberation. While nurse practitioners are intelligent, capable, and contribute much to our healthcare system, they are not physicians and lack the same training and knowledge base. They should not identify themselves as ‘doctors’ despite having a Doctor of Nursing Practice (DNP) degree. It is misleading to patients, as most do not realize the difference in education necessary for an MD or DO compared to a DNP. Furthermore, until they are required to pass the same rigorous board certification exams as physicians, they should refrain from asserting they are ‘doctors’ in a society which equates that title with being a physician.”
Dr. Al-Agba’s point is that compared to a DPN’s 1,000 patient contact hours required for graduation, a physician has accrued a minimum of 20,000 or more hours of clinical experience. In a society ruled by market forces, however, a qualified and licensed DPN provides a cost-effective way to expand treatment and provide better health outcomes for those not currently able to access quality care. Yet, Al-Agba cautions, “As health care reform focuses on cost containment, the notion of independent nurse practitioners resulting in lower health care spending overall should be revisited. While mid-level providers cost less on the front end; the care they deliver may ultimately cost more when all is said and done.”
Al-Agba cites a cautionary tale of an independent DNP and how the limitations of experience and training can put patients in danger. She relates a story about a first-time mother being referred to a nurse practitioner who owned and operated a pediatric practice and referred to himself as a doctor. When the baby exhibited sweating, increased respiratory rate, fatigue with feedings, and wasn’t growing and gaining weight, the DPN was not helpful. The situation went from bad to worse. Al Agra explains, “By two months of age, the baby was admitted to the hospital for failure to thrive. A feeding tube was placed to increase caloric intake and improve growth. I have spent many hours talking with parents of children with special needs who struggle with this agonizing decision. It is never easy. A nurse from the insurance company called to collect information about the supplies, such as formula, required for supplemental nutrition. Mom was so distressed about her daughters’ condition, she could not coherently answer her questions. As a result, the nurse mistakenly reported her to CPS for neglect and a caseworker was assigned to the family.”
Finally, the young mother visited a licensed pediatrician and the baby’s true condition came into focus. As Al-Agba explains, “An echocardiogram discovered two septal defects and a condition known as Total Anomalous Pulmonary Venous Return (TAPVR), where the blood vessels from the lungs are bringing oxygenated blood back to the wrong side of the heart, an abnormality in need of operative repair. During surgery, the path of the abnormal vessels led to a definitive diagnosis of Scimitar Syndrome, which explains the abnormal growth, feeding difficulties, and failure to thrive. This particular diagnosis was a memorable test question from my rigorous 16-hour board certification exam, administered by the American Board of Pediatrics.”
Pediatrics is particularly vulnerable to misrepresentation and error because the patients can’t question their own treatment, and their chief advocates are often inexperienced or lack confidence in their decision-making ability. Referencing the case cited, Al-Agba concludes, “Choosing a pediatrician is one of the most significant decisions a parent will make. This child faced more obstacles than necessary as a result of the limited knowledge base of her mid-level provider. A newly practicing pediatrician has 15 times more hours of clinical experience treating children than a newly minted DNP. When something goes wrong, that stark contrast in knowledge, experience, and training really matters. There should be no ambiguity when identifying oneself as a ‘doctor’ in a clinical setting; it could be the difference between life or death.”
Not everyone shares Dr. Niran Al-Agba’s point of view. Twenty-three states allow NPs to have a private practice without physician oversight. And many nurses’ associations and organizations are pressing for pay equity and expanded treatments privileges for nurses with advanced and specialized degrees.
In “MD vs. NP – Let’s Put Egos Aside and Patients First” for Nurses.org, author Miriam Yazdi acknowledges the heightening stress between medical doctors and nurse practitioners and attributes this to disputes over wages and a clashing of egos.
In regard to wages, Yazdi explains, “Many facilities employ nurse practitioners in settings where they will assess, diagnose, treat, prescribe, and get paid a smaller salary than a doctor would for performing those same tasks. Especially amongst the twenty-three states that allow NPs to practice independently without physician oversight, there is a big movement towards equal pay grades between the two providers. So what is the best thing to do? Pay all providers giving the same service the same wage? Or calculate salaries that are commensurate with schooling, training, and scope of practice? From a corporate perspective, the answer is easy. Companies will always find an excuse to tip the pay scale to their benefit, and level of education is a perfect pretext. We see it in the pay difference between ADNs and BSNs, between LPNs and RNs, and subsequently with NPs and MDs.” As long as the debate rages and perceived inequity exists without a reasonable solution proposed, the tension continues.
Yazdi concedes that the title of “Doctor,” which is used by NPs when dealing with patients is particularly vexing to physicians. She sees it as a debatable issue but thinks both sides can agree on one thing, “No matter who you are or where you stand on each argument, it can be said that ego lies at the center of the feud.” Wright disagrees. “While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted.”
And even the greatest advocates for more NPs with expanded scope of practice and pay equity concede that ego goes both ways. Yazdi observes, “As imperfect beings, we look for validation, whether it be from others or from our own selves. Yes, the lobbying toward and against both professions will likely continue. Yes, there will be moments where an NP will not correct patients when they are called ‘doctor.’ Yes, there will be moments where a physician will feel threatened by the growing number of advance practice nurses.”
In the end, the stakes are too high not to resolve this conflict between health care professionals. The first step might be to agree to disagree on some basic tenets of care.
In “NP, PA or MD? Deciphering Your Healthcare Career Choices” for the Atlantis Global blog author Kasey Isaacs presents a simple explanation of the health care organization flow chart. “Physicians and other clinicians share many similarities, but also a number of differences. No matter the part you play, an effective health care system takes a full team of professionals to run efficiently. Although every member is vital, physicians act as the leaders. Contrary to what some may think, this does not imply an elevation of status, but rather a willingness to serve and bear the burden of intense education, long hours, frustrating systems, mountains of paperwork, and great responsibility.”
But he does not diminish the importance of nurses and physician assistants. “In recent years, however, NPs and PAs have taken on more autonomy and responsibility as many doctors have moved toward specialties and hospital employment. The trend is multifaceted and may be attributed to a series of interconnected issues including rising medical school tuition (prompting students to seek a higher paying specialty), the primary care provider (PCP) shortage, changes in health care culture, faster tracks to practice for PAs and NPs, and of course political influence.”
For Isaacs, everyone has a role to play and the important thing is to play your part well. “Ultimately, whether you aspire to be an NP, PA, MD or DO, remember this: whichever health care path you choose, your priority must always be to provide the highest level of patient care. In what other world do the decisions so often literally mean life or death?” •
*The name of the individual has been changed to “Marsha” in this article to protect identity.
There was a time you could ignore the business card holder next to the sign in sheet at your doctor’s office, but times have changed. A simple business card can tell you what kind of training your health care providers have, if you can crack the code of the initials at the end of their names. One thing is certain: you can’t assume they are MDs unless it expressly says so on the office door or on their cards. But you can be well-informed about what your health care provider can and cannot do for you.
In her article, “Alphabet Soup: LPN, RN, APRN, NP - Making Sense of Nursing Roles & Scope of Practice,” Melissa DeCapua, a board-certified psychiatric nurse practitioner who graduated from Vanderbilt University, lists the many options available to nursing students as they navigate higher education lanes. Here’s how we break down those degree choices.
• Associate’s Degree in Nursing (ADN) – When we think about nursing, an ADN is what we’re most familiar with. A caregiver, ADNs conduct monitoring tests like blood pressure and temperature, administer doctor-prescribed medicine, change bandages, keep medical records and conduct diagnostic tests.
• Bachelor of Science in Nursing (BSN) – Those with BSN degrees are qualified to fill many different positions including nurse managers, case managers, pediatric nurses, public health or critical care nurses, as well as perform the duties of a ADN.
• Master of Science in Nursing (MSN) – The MSN can specialize to work in surgical or maternity wards or hospital ERs. They can diagnose conditions and write prescriptions, and some become higher education teachers to train new nurses.
• Doctor of Nursing Practice (DNP) – A DNP manages staff and other nurses. They can start their own private practice and narrow their expertise to one specific type of discipline. They can also become researchers or public health lobbyists.
Of course, holding any of the above degrees is only part of the health care picture that determines their scope of practice. They must also be licensed by approved licensing councils or boards like the American Nurses Credentialing Center and American Association of Critical-Care Nurses.
Should you demand a MD every time you need medical attention? Not necessarily. Will your health care facility make your options clear to you? Not necessarily. Should you educate yourself about the abilities and limitations of the person treating you? Absolutely. •
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