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Majestic82

family medicine and nurse practitioners

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Hey,

 

I'm a first year med student right now, thinking about what specialty I eventually want to go into. I am strongly considering family medicine, however one of the things holding me back are all the rumours out there saying that nurse practitioners will eventually be replacing family doctors. Some family doctors that I've spoken to say that this will never happen, but I know that the nurse practioner association is actively campaining to be family doctor substitutes and that a few nurse practitioner-led clinics have already opened up in Canada (ie. Sudbury), with more on the way.

 

I'm just wondering what everyone thinks of the whole nurse practitioner issue right now. Is it something that I should rightly be concerned about when choosing my residence specialty?

 

Looking forward to your responses.

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Never happen.

 

I agree they are covering care that family docs have done in the past, but that simply frees the doctor to handle more patients and more complicated cases. That is what they were created for, and they excel at it. Simply put, nurse practioners have the training to deal with sore ankles and the flu...freeing doctors to deal with cancer cases and CHF etc. Nurse practioners aren't meant to replace family doctors, they are meant to help them do their job more effectively.

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No opinion on whether NPs will take over the FP role.

 

However, one thing I don`t seem to grasp in this whole thing is how you can justify taking nurses away from their jobs due to a shortage in family docs.

 

It isn`t like we have excess nurses floating around...we also have a nursing shortage, not just a doctor shortage. At a local hospital I have been on call and seen them shut down the maternity ward because they didn`t have enough nurses to work that night. The same hospital cut back on days the OR is open...due to a nursing shortage, not a doctor shortage.

 

So we take nurses and give them extra training so they can fill a different role.

 

My question is...who is left doing the nursing??

 

To me NPs just don`t seem like a good solution to our healthcare issues.

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My question is...who is left doing the nursing??

 

 

The bean-counter's response would be to replace the RNs with RPNs.

 

NB: I'm not saying that's a good idea, but that's the way administrators and bureaucrats think...

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Well, it seems to me that everyone likes the idea of nurse practioners until it is them or more importantly their family that is sick. Then they will want the doctor. Nurse practioners do not have a defined role and make an already gray area of care even worse. If a family doctor, I think, needs to see the bread and butter cases 100 times until they can see something is wrong 'just because'.

 

Anyway, to FP good luck. Everyone thinks they have the answer when they come to your office from their naturalpath, family member who is a nurse, or the internet. I would recommend going into surgery since no one will ever try to cut someone open without training.

 

good luck.

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I would recommend going into surgery since no one will ever try to cut someone open without training.

Surgeons have their fair share of problems too. Maybe a better advice would be the ROAD to happiness (rads, ophto, anesthesia, derm) or whatever else that really floats your boat, I guess.

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Nurse practioners do not have a defined role and make an already gray area of care even worse.

 

Not sure if this is quite true although I think I know what you're getting at . . . NP's do have a legally defined role and a set-out scope of practice. Of course, depending on an NP's practice setting, his/her actual job responsibilities will differ, but that's partly true for doctors as well.

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NPs are one more reason to avoid going into FP.

 

I've been saying this for a long time: family medicine is in a dire position right now, and its only going to get worse.

 

If any premed or med student asks me what I think about family medicine, I tell them to avoid it unless they were completely enthralled by its philosophy. The field is facing enough problems as it is, and the future looks bleak.

 

Follow the numbers: less students are going into FP every year. Medical students are not fools - they as a whole realize that FP is a total lemon of a career choice right now.(yes, I said it.)

 

If they're unsure of a career choice, I tell them to go into internal since it allows one to explore more options than family med.

 

Honestly, I would not be surprised if family medicine was primarily a nurse's responsibility in the future. An unfortunate, dismal prognosis which is more politically feasible than recruiting more doctors.

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Valetine, I truly hope you don't get bashed for saying the truth (although i think you will, quick run for the hills!).

 

Frankly the idea that nurses would be given that much responsibility scares the hell outta me. Now I know a bunch of pro-nurses (if there are any on this site) are going to go nuts on that statement. The fact is that my mother is an RN (now homemaker but back when i was a child she was). My family didn't start off well off, so there were many days where I was babysat by all the nurses and technicians, (medical labs ARE the funniest place to be when you are a five-year old kid, especially when a crazy jamaican lady works in the lab). Later in life it became my place to hang out, while I waited for my mother to get off work.

 

So if I was an uncaring person, I would say whatever let them treat someone else. But really no one wants a nurse doing a doctor's job when it comes to their family.

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Come on Valentine, FP is a great lifestyle if you want it to be, and you get $$$ if you want to work for it. It allows you to do a lot of different things, and you cover a wide range of fields...doing locums, ER...cruiseship medicine...

 

As a FP you can do fellowships in EM, Anes, OB, palliative, Geri...etc.

 

Most hospitalists (sort of internist) in rural/regional health centers are FPs...

 

I don't see NPs "stealing" jobs from FPs, rather helping them with less complicated cases and freeing time...

 

There is a huge shortage of FP docs...don't see a problem of going into FP at all for job perspectives...

 

noncestvrai

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Come on Valentine, FP is a great lifestyle if you want it to be, and you get $$$ if you want to work for it. It allows you to do a lot of different things, and you cover a wide range of fields...doing locums, ER...cruiseship medicine...

 

As a FP you can do fellowships in EM, Anes, OB, palliative, Geri...etc.

 

Most hospitalists (sort of internist) in rural/regional health centers are FPs...

 

I don't see NPs "stealing" jobs from FPs, rather helping them with less complicated cases and freeing time...

 

There is a huge shortage of FP docs...don't see a problem of going into FP at all for job perspectives...

 

noncestvrai

 

Thank you, noncestvrai, I agree wholeheartedly with this and also one of the comments above about advanced practice nurses really being there to help doctors work more effectively.

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NPs are one more reason to avoid going into FP.

 

I've been saying this for a long time: family medicine is in a dire position right now, and its only going to get worse.

 

If any premed or med student asks me what I think about family medicine, I tell them to avoid it unless they were completely enthralled by its philosophy. The field is facing enough problems as it is, and the future looks bleak.

 

Follow the numbers: less students are going into FP every year. Medical students are not fools - they as a whole realize that FP is a total lemon of a career choice right now.(yes, I said it.)

 

If they're unsure of a career choice, I tell them to go into internal since it allows one to explore more options than family med.

 

Honestly, I would not be surprised if family medicine was primarily a nurse's responsibility in the future. An unfortunate, dismal prognosis which is more politically feasible than recruiting more doctors.

 

1) The trend of fewer students going into family is actually shifting, so I disagree there.

 

2) I have no idea how the future looks bleak when there is a greater demand for family physicians now than there ever was and it is by FAR the best field to go into if you want to work where/when you want. To say the future of family medicine is bleak is crazy. If anything, the future has never been stronger, as political pressure at every level has resulted in incredible advances in family medicine work environments, and pay (family health teams coming to mind).

 

3) People on here keep talking about how the scope of practice is being shifted downwards down the specialization line from family doctors to NPs, to RNs, to RPNs, but they forget that family docs are doing more and more "specialized work". And it isn't like they are turning out NPs right now.

 

4) Finally, nurses in general won't replace family physicians. NPs will help with the tremendous demand for the family docs by gaining some of their scope of practice. And for those who think it is scary that NPs may be given this responsiblity, I remind you that they receive two years additional training, and are particularly trained in knowing when they are in over their head.

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I personally am very concerned about the influx of nurse practitioners into the medical system. As many of you know, I am doing my radiology residency in the US, after having done my medical school training in Canada. I've therefore had a chance to see both sides of the equation.

 

Particularly, as a radiologist, I'm privy to a very extensive set of interactions with physicians and mid-level providers across the entire spectrum of specialties, in both the inpatient and outpatient settings.

 

Frequently, we are consultants to the primary team. We are constantly calling in results to the ordering physician/mid level provider, and therefore, I get lots of opportunities to see what the underlying knowledge base is of that referring physician/mid level.

 

It is almost uniformly the case that mid level providers order more imaging tests, and order them inappropriately, with no real understanding of what constitutes the best test for a given condition. When there is a positive finding, or even better yet, an incidental finding, they are much less likely to know how to handle or manage that finding.

 

In short, they don't have that depth or breadth of knowledge of clinical medicine that physicians do, and I find that frightening. I find it even more frightening that they are currently in a struggle to take over a significant amount of turf in primary care, where a broad knowledge base is absolutely essential to practice safe medicine.

 

I've actually argued personally with a nurse practitioner at one of our institutions who claimed that because she was "board certified" as well, that she was just as capable as any other primary care physician. Now, they are coming out with the DNP (Doctorate of Nursing Practice) degree so that nurse practitioners can claim to have a clinical doctorate degree. In essence, the "doctor nurse." Talk about finding ways to confuse patients further.

 

As it stands now in every US hospital I've worked with, these mid level providers wear the same long white coats with the same tiny illegible ID tags that the rest of the physicians wear. It's physically impossible to figure out whether they are physicians or mid levels until or unless they introduce themselves properly, and as you'll see on this thread in the AllNurses forum, many of them see nothing wrong with them using the "Doctor" title in a clinical setting.

 

http://allnurses.com/forums/f34/curious-using-title-doctor-dnp-296861.html

 

We actually nearly got into a huge problem a couple months ago on one of my body rotations. A white-coated, scrub-wearing male in his 40's came down to our reading room, introduced himself as "Jim, one of the surgery staff", and asked us to perform a procedure on one of the SICU patients. In general, we've got a pretty good working relationship with the surgeons, and so we told him that we'd look at the imaging, and then try to get the patient worked in for the procedure that afternoon.

 

Well, the more we looked at all the imaging and the labwork, the more we realized that this was an entirely inappropriate, even dangerous, procedure to be performing at this time. So, we paged the surgery resident that was covering this patient, and discovered that "Jim, one of the surgery staff", was actually "Jim the nurse practitioner, recently hired on staff", and more importantly, was in no way authorized to have ordered that procedure at that time. It was just something that was going to be considered if the patient didn't start clinically improving soon.

 

The trouble is that as the lines between physicians and non-physicians blur further, you still need someone as the designated leader of the team. Even though everyone is now wearing scrubs and a long white coat in the hospital, it still behooves us that the individual with the greatest knowledge base and clinical experience leads the team and bears primary responsibility for the clinical outcome, and that is an MD-holding, board certified physician.

 

As far as NP's or PA's replacing primary care physicians, that is a scary thought. A lot of sinister conditions can present with common signs/symptoms, and quite frankly, it's absurd to say that NP's and PA's can be trained well to spot the zebras if they don't have the background knowledge to identify them.

 

I've never met an NP or PA that has challenged my reads or my attending's reads. If I tell them the chest xray looks like a pneumonia, that guy is going off to the pharmacy to collect his antibiotic prescription. In contrast, physicians commonly come down to the reading room to argue with us about reads, stating that our interpretation doesn't match with the clinical presentation.

 

It's usually when that imaging:clinical presentation discordance occurs that we discover that it's a zebra manifesting as a common condition, such as the broncho-alveolar carcinoma masquerading as a pneumonia. Or the chronic shoulder pain being due to a Pancoast tumour rather than arthritis. Or the subtle periostial changes in a femur in a peds patient being an early Ewing's sarcoma. Or a subtle metaphyseal corner fracture manifesting as the sole sign of child abuse. Or a male presenting with breast cancer, etc, etc, etc.

 

I've seen all of these things because my specialty of radiology is basically a sieve for zebras.

 

I feel much more pressure whenever I'm reading a study ordered by a PA or NP, than I do if I see a similar study that was ordered by a specialist physician. Ironically, even though the study is much more likely to be stone-cold normal, if I miss the lesion or suggest an inappropriate follow-up, it will entirely derail or halt the workup if the patient is being managed by a midlevel. On the other hand, that's when the specialists will often give me an angry phone call, or visit in the reading room to suggest that I might have blown the case. In other words, the specialists have my back, because they have the clinical knowledge and confidence to suggest that I might be wrong. I've never seen that happen with a PA or NP, which means that a mistake can slip through the cracks much more easily.

 

The bottom line is that there is a shortage of primary care practitioners, and both Canada and the US need to make serious changes in medical education and medical financing to make primary care an attractive practice proposition. I think the answer lies in making primary care a viable and sustainable specialty, and if you can make it so, then physicians will follow into those fields.

 

A huge mistake would be to try to supplant or replace primary care physicians with less well trained, and cheaper midlevels. Particularly in Canada, where the primary care physicians have a wider scope of practice than in the US (where everyone gets a referral since there's an army of specialists waiting to take in patients), it's absolutely crucial to maintain that high standard of clinical knowledge and experience.

 

One thing is absolutely for sure, and you just need to look to the US as an example of this. There has NEVER been a midlevel group that has remained content within its limitations. They ALL seek to expand their practice rights, and often they do so not by increasing their education, but rather by legislative means. NP's, PA's, CRNA's (certified registered nurse anesthetists), optometrists, physiotherapists, etc are all trying to increase their scope of practice.

 

Once those expanded practice rights are given, they are next to impossible to take away.

 

Canada needs to be very cautious when/if these midlevels gain a wider acceptance in our health care system.

 

Ian

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To say that NPs would never take over the role of an FP is not 100% certain (Never say never, The B). Currently in nursing school, students are taught that RNs can do 70% of what an FP does in the office. NPs can do more than that.

 

 

If this is true, then this is very concerning. Graduating nursing students will feel as if they are capable of performing the job of a doctor. Thus, they will lobby strongly for legislation that will give them more power, and thus more money, for less education and for less concern about patient care. Think it's crazy? It's happening in the USA right now; just read Ian's post.

 

As a counterpoint, if an RN can truly do 70% of what an office FP can do, then do we need so many office FPs?

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I heard a cbc podcast discussing the evolving role of NPs and PAs. It was interesting to listen to anyhow, I'd be interested in anyone's comments about it!

 

http://podcast.cbc.ca/mp3/whitecoat_20080428_5504.mp3

 

 

Wow.

 

It really is becoming a huge issue. Doctors, and students, should be very aware of this.

 

Nurse Acorn, from the podcast, presents her case as an NP by suggesting that it is not a replacement for doctors, but in reality that's exactly what it is.

Also note her emphatic "yes" to when asked if NPs can do what family doctors do. Wow.

 

Personally I am unsure as to what kind of training NPs gather as compared to family doctors, so I cannot comment on whether or not they should replace family doctors as a cheaper alternative. Nonetheless, with the current doctor shortage and the medical system being entirely overbudget, NPs will be utilized to a much greater extent than they are currently.

 

Thus, the future for the family doctor seems a bit shaky. NPs and PAs will be fighting over turf and payments. Since they are a cheaper, more numerous alternative, they'll get what they want. FPs will somewhat disappear as a field, like they have in the US. Same goes for anesthesia. Right now Canada has exceptionally high standards for anesthetic use, but as with the US, this will be replaced by cheaper CRNAs.

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Wow.

 

It really is becoming a huge issue. Doctors, and students, should be very aware of this.

 

Nurse Acorn, from the podcast, presents her case as an NP by suggesting that it is not a replacement for doctors, but in reality that's exactly what it is.

Also note her emphatic "yes" to when asked if NPs can do what family doctors do. Wow.

 

Personally I am unsure as to what kind of training NPs gather as compared to family doctors, so I cannot comment on whether or not they should replace family doctors as a cheaper alternative. Nonetheless, with the current doctor shortage and the medical system being entirely overbudget, NPs will be utilized to a much greater extent than they are currently.

 

Thus, the future for the family doctor seems a bit shaky. NPs and PAs will be fighting over turf and payments. Since they are a cheaper, more numerous alternative, they'll get what they want. FPs will somewhat disappear as a field, like they have in the US. Same goes for anesthesia. Right now Canada has exceptionally high standards for anesthetic use, but as with the US, this will be replaced by cheaper CRNAs.

 

I just don't buy this argument that family docs will be fazed out. If I could hear of ONE family doctor who couldn't find patients because he lost them to a NP, then just maybe. I'll admit, family docs will increasingly deal with fewer benign problems that patients need reassurance/guidance with, but family doctors do a lot more than that, and have an ability to deal with much more complicated things. I've never heard a family doctor say they were worried about NPs. They all say it makes their practice easier to manage and allows them more flexibility in the type of cases they see.

 

Now I'll admit that Nurses are pushing for more power, and no doubt wish to have an ever increasing role in health care/a great scope of practice, however I believe that they will only be able to push until the point of "filling the gap" created by insufficient numbers in family medicine. There would be little support in a community for an NP instead of a family doctor, however there will be an acceptance of an NP instead of nothing. This is why I believe it won't happen that they will "replace" family doctors.

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NP's make around 80,000$+

 

 

Ok, first of all, I dont think you have the right to bash Nurse Practioners.

 

Here's the education they receive:

 

1) Bachelor of Nursing - 4Years (WAY more related to Health Care than any other Bachelor program... no offense)...

 

2) Min 2+ Years [that's like saying a 3/4GPA gets you in McMaster Med (Minimum I've seen is 5 years+ of experience) in a special field in order to be considered for a Nurse Practioner program.

 

3) 2 Years of Nurse Practioner Program.

 

So far, minimum 10 Years of training.... now doctors route:

 

1) Bachelor of ____ - 4Years(most times Science, and almost no hands-on skills whatsover towards dealing with patients)

 

2) Med School 4 Years

 

3) Family Res - 2 Years

 

Meaning minimum 10 years... to be a family doctor.

 

With all of the experience Nurse Practioners have, they should be allowed to practice as a GP; and moreover, this initiative's already in play with DrNP programs in the states. (in Canada, it'll come in a few years)...

 

Nurse's just dont have that "Doctor" prestige, but it doesnt make them inferior; (with DrNP, it's no longer Nurse practioner, but "Dr.").

 

Yeah, I admit some nurses are just stupid, but I also gotta admit there's some pretty stupid doctors out there as well...

 

-Stef

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With all of the experience Nurse Practioners have, they should be allowed to practice as a GP;

 

-Stef

 

Just curious what else NPs should be able to practice as, cardiologists? endocrinologists? dermatologists? psychiatrists? Nurses do have experience in all of these areas so if they should be allowed to practice as a GP should they also practice as specialists?

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Just curious what else NPs should be able to practice as, cardiologists? endocrinologists? dermatologists? psychiatrists? Nurses do have experience in all of these areas so if they should be allowed to practice as a GP should they also practice as specialists?

 

Gee I sure hope that's not sarcasm? . . . cos I would find that sort of offensive.

 

I'm a nursing student. I do realize that NP does NOT equal family doctor. I realize that 10 years of nursing education does not produce the same product as 10 years of medical education.

But I agree with some of what stef has said, eg. you don't have the right to bash NPs- as a doc, they are health care professionals in their own right and part of your team. They certainly are not inferior, in theory, but unfortunately in practice people place value on money, power and the perceived prestige, and docs 'win' in people's eyes in that regard.

 

I think I'm at a unique position; being in nursing but really considering medicine. Sometimes I would like to yell at both factions- GROW UP!

Nurses- if medicine is what you want then go for it. Or, be happy in the specialized roles you can enjoy as a nurse- flight nurse, NP, nurse anesthetist, etc and be proud of yourself and your job. Trust your years of experience, but remember to work with the doctors too.

Doctors- Yes, be proud of yourself and your job!- but don't sit so high on your horse that you degrade others and misuse your power. Don't enter your career (or med school at that) with a superiority complex! Try to be flexible: health care is changing (ie. 'interdisciplinary'); it must be hard for you when you feel that your turf is being invaded.

 

Both nurses and doctors- remember to respect each other and work together . . . different roles, SAME team.

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Well said..

 

NPs are all trained by subspecialties, just like MDs...

 

NPs can only be specialists in a certain field (their NP master's degree, is in a specific field), and with more education and experience, they can definately become qualified enough to be able to make diagnoses just as well as an MD.

 

They cant do surgery, or some MD subspecialties (yet), such as being cardiologists, but can work in a CTU and make appropriated diagnoses.

 

Right now, CRNA's (in the US) are as far as being almost working on their own as anesthetists.

 

And also, do keep in mind that at least Nurses are quite qualified, i probably think you didnt hear whats happening with Dentists....hygienists want to open up their own dental cleaning places and pretty much take over the Dentist's jobs entirely (most of the dental income comes from cleanings).

 

MD's will still be required, nevertheless you have job security...but you gotta keep in mind that in the future their plans are probably having super-qualified nurses and 1 Head MD that oversees it all.

 

-Stef

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