Stop the nurses before it's too late

[runningdoc]

I have two friends in Naturopathy in Canada who are working their butts off doing something they believe in. It's time you stepped down from your self-rightous pedestal... the only people we need to stop is people like you.

 

I do always enjoy a good holier-than-thou scolding in response to a holier-than-thou line of thinking.

[Hushwawa]

I do always enjoy a good holier-than-thou scolding in response to a holier-than-thou line of thinking.

 

Haha... point taken, didn't mean it that way, just thought about how they'd feel if they'd read that post, I got annoyed... could you tell? lol

[Chantoogle]

You're a gigantic douchebag. You were also wrong. WRONG. I'm not sure if you understand the concept. It's like when you give a patient the wrong medication (which I'm sure you've done, many times) but you refuse to apologize because that patient was a **** to you.

 

I have nothing to say about your profession. But.. *pulls down pants and drops a big one*... here's one for you, ya worthless piece of sh*t.

 

/this post will soon disappear so enjoy it while you can, kids!

 

...and you're TOTALLY the type of person I'd want to be my physician, in charge of my health. I've met toddlers more mature than this.

[Mourning Cloak]

The problem with NDs is that some of them are selling therapies which are unproven, ineffective or frankly dangerous. The following quacks claim the ND designation and are practicing in Canada.

 

Pragnall ND in Ontario practices classical homeopathy. Can you say Avogadro's number? Or maybe you'd like live blood analysis from Turk ND in Ontario? Feel like some ultraviolet blood irradiation or worse from Ward ND? Or maybe you'd like Hyperbaric Oxygen Therapy from Nardella ND in Calgary for completely no reason at all? There are indications for this therapy . . . unless, of course, you're "Dr." Nardella. Maybe you're more in the mood to waste time and money on electrodermal screening via NDs Meier and Kuindersma in Ontario or Tonskamper ND in BC? Or "arterial stiffness" and chelation by Brown ND? And for a little bit of all of the above along with lots of personalized hand-holding, you can check out Fabricus ND whose initial H&P takes, on average, six hours.

 

And then there's those real sweethearts who do panels of complicated, highly non-specific testing that they couldn't possibly interpret for no particular reason at all (except for the revenue, of course). My example is Ling ND in Toronto who pushes estradiol, progesterone, cortisol and DHEAS as a screen for . . . are you ready for this? Heart disease. And breast cancer. And if you need a link for this, dear med student, you need to study more.

 

And then there's the money grab that is heavy metal analysis in hair. What are is the normal range for heavy metal in the hair? If an abnormal range is defined, what does an abnormal value mean in the absence of symptoms? Before you start googling like mad, look here.

 

I suggest the following supplemental readings:

Ed's Guide to Alternative Therapies; see also Quackwatch; definitely check out this article on how to spot pseudoscience!

[A-Stark]

Well, I've had a patient who went to an osteopath who told her that her liver was "hard" and recommended some concoction to "cleanse" it. Sigh.

[Rosie]

Speaking of homeopathy

 

Emergency Homeopathy it's hilarious I promise

[Der Kaiser]

Amen MC.

 

I've been saying this for a while: primary care is a dying field. We as a profession have abandoned it. We've transferred the value we once placed on general medical knowledge to superspecialized throughputting.

 

Lower pay vs every other specialty save peds and psych? More headaches and expense? Less respect? Less chance for career advancement? Who in their right mind would gamble on this?

 

Instead of doing what any sane organization would do and reinstate the general license for everyone, we've instead made the field that is in the most need of practitioners too exclusive for its own good.

 

There is a power vacuum. Someone wants to fill the void - in this case it is naturopaths and midlevel providers. Cheaper, more dangerous alternatives to traditional medically trained physicians. Who cares about patient safety since primary care isn't really medicine anyway? All we need as physicians are gatekeepers/secretaries to give us consults.

 

I think we can wave bye bye to family medicine being occupied by solely physicians.

 

As far as I know the pay for GPs is pretty good in Ontario now. Plus, only two years residency! Still, the option for specialty training should be there if one were so inclined (later).

[PAstudent]

As far as I know the pay for GPs is pretty good in Ontario now. Plus, only two years residency! Still, the option for specialty training should be there if one were so inclined (later).

 

I have a few friends who recently (last year or so) finished their FM residencies and they are making as much (or as little) as they want. Several of them are also doing emerg shifts (though none of them did a plus one year). One of them is making about 50 grand a month combining FM with lots of rural emerg. One of the things that attracts me to being a PA is the notion of being a generalist allowing me to work in different specialties and switch stuff up. That's the same thing that caused many of my MD friends who, before med school, originally wanted specialties to decide to do FM. There is a great deal of flexibility and you can basically structure your practice as you want it and there is plenty of money to be made if you want to work for it.

[apache]

You bring up some good points, as usual, Brooksbane.

 

To counter some of your points, I'd like to bring up a few perceived advantages of family medicine:

 

-2 year residency

-flexibility, I can work in the ER, and do an extra year in medical psychotherapy, allowing me to do broad range of things

-jobs are everywhere, you can live wherever you want

-no hospital bureaucracy

-not everyone cares about respect and career advancement, i just want a good paying, yet enjoyable job to allow me to enjoy my life and pursue other endeavours

-pay is a relative thing, 200 k a year may not be a lot compared to rads, but it's certainly enough for many people, given the other perks

 

one thing i do agree with you in though is the fact that everyone should get a general practice license and then have the option to go into a specialty later. i'm considering getting an fm license and then going back for re-training, but i'm fortunate that my primary specialty of interest besides fm has lots of second round spots, i don't think i would consider this route if i was set on optho or something similar.

 

i know psychopharmacology in and out and i will admit, i go to herbal places to get some supplements that have shown to be effective in its desired effect (N-Acetyl Cysteine for OCD, Inositol for depression, Huperzine A for memory, enhancement, melatonin for sleep, kava kava to relax plus a million other products), however, listening to the advice that the workers at the establishment give visitors and the advice the naturopaths had given the visitors i often find myself shocked that these people (the ND's) have licenses, it's also interesting to note, that unless your willing to buy the most expensive products, most of the products are not pharmaceutical grade and won't do ****. personally, i think it would be more appropriate for mds with an interest in (non bull****) naturopathy to be able to do an extra year after fm to extend their practice to naturopathy.

 

i really think this issue needs to become less black and white because there is some good naturopathy out there and i really feel bad that it gets lumped in with all the quack naturopathy out there.

 

as to the future of family medicine, i really can't comment, because i really don't know...

 

Amen MC.

 

I've been saying this for a while: primary care is a dying field. We as a profession have abandoned it. We've transferred the value we once placed on general medical knowledge to superspecialized throughputting.

 

Lower pay vs every other specialty save peds and psych? More headaches and expense? Less respect? Less chance for career advancement? Who in their right mind would gamble on this?

 

Instead of doing what any sane organization would do and reinstate the general license for everyone, we've instead made the field that is in the most need of practitioners too exclusive for its own good.

 

There is a power vacuum. Someone wants to fill the void - in this case it is naturopaths and midlevel providers. Cheaper, more dangerous alternatives to traditional medically trained physicians. Who cares about patient safety since primary care isn't really medicine anyway? All we need as physicians are gatekeepers/secretaries to give us consults.

 

And on the previous page there is a post from someone who appears to be a ND vehemently defending the practice of naturopathy. To him I say: if a naturopath wants to provide patients with unproven treatments that have been shown at most to be ineffective, then I say go for it! Otherwise, to harm patients with expensive snake-oil, or to practice true allopathic medicine without the deep knowledge of science that is required to be safe and effective, is wrong and cannot be supported. And to his other comment about ND students being competent and having the same prereq requirements as MD students: they may have the same prereqs but they certainly do not have the same GPA cutoffs. NO contest.

 

I think we can wave bye bye to family medicine being occupied by solely physicians.

[fever]

This may be a little off topic, but I saw the subject referenced here so I thought why not ask the question.

 

Are specialists (ex. a surgeon) allowed to run their own family practice clinic?

 

Is this different in the US?

[NLengr]

Speaking of expanding roles of mid-levels:

 

http://www.cbc.ca/news/health/story/2011/05/05/ontario-midwives.html

 

They don't give much information on how these would be set up. I don't know if they would have emerg. c-section facilities on site, or within a certain amount of time, or if they are essentially a "home" birth in a centralized location.

[seeking1]

Speaking of expanding roles of mid-levels:

 

http://www.cbc.ca/news/health/story/2011/05/05/ontario-midwives.html

 

They don't give much information on how these would be set up. I don't know if they would have emerg. c-section facilities on site, or within a certain amount of time, or if they are essentially a "home" birth in a centralized location.

 

Responding to the main thrust of their argument, saving $50 million/year isn't particularly significant and hardly dents the cost problems that we are having.

 

They also make it sound like c-sections would tail off or cease entirely at these centres, which is silly. Even if they made these centres, why not just have GPs and OB/GYNs running the place instead of midwives? After all, there are a number of high-risk (and high-cost) pregnancies which can only be handled by well-trained doctors.

[seeking1]

With regards to nursing positions: as I've come to understand it, the USA has engaged in a policy for the past 50 years which systematically hires away the nurses we train here. They do it by providing amazing working incentives.

 

Given the recent (see: past 10 years) turn-around in our treatment of nurses in Ontario, I am not surprised that more of them are trying to move into diagnostic and leadership roles.

 

However, given the recent focus on family physicians and the introduction of physician assistants into the system, I do not understand why we would try to restructure nursing such that we graduate more nurse practitioners. I do agree that there is a lack of training for NPs compared to GPs or family docs, and that this could be harmful to individual patient and population health in the long run.

[questforstarfish]

 

We need to take pride in what we do. Otherwise, other less skilled people will think they can do it too. Then we all suffer: we lose marketability, the midlevels get sued, and the patients suffer.

 

 

I live in a city of 90 000 in BC (where doctors are paid more than most of the rest of the country) and 75% of the people I know here do not have a family doctor. We have very few of them here and despite the generous compensation packages and lovely environment with access to recreation and beautiful homes, it is very difficult to recruit doctors here. Quite frankly, every person I know would rather have an NP than no one.

 

The costs of ER visits are rising and the overcrowding is too because no one has anywhere to go for problems that can be dealt with in primary care. NP's can diagnose and treat COMMON illnesses, and make countless referrals for other problems. If you want to slag on the members of our society getting training to make up for the severe shortage of doctors and the shortfalls in health care, you should take a look at how busy doctors are in the real world. They haven't the time, resources or numbers to do everything that the population needs.

 

Demands are growing by the day and doctors CAN NOT MEET those demands alone. We need a team. Nurses are taking on more responsibility just as doctors, LPNs and care aids are. It has to happen.

[cheech10]

The problem is not treatment of common illness. Any algorithm can do that. The problem is diagnosis, where many uncommon and potentially life-threatening illnesses have only subtle differences from common benign conditions. Algorithms don't help much here. Another issue is dealing with complications. These are the situations that a residency-trained MD deals with better than an RN/NP/PA.

 

I'll give a common example. Pink eye is usually due to viral conjunctivitis. It's very easy to dismiss patients with red, painful eye complaints as pink eye, and send them home with artificial tears. But you need experience and training to differentiate viral conjunctivitis from glaucoma, which is can lead to permanent loss of vision, iritis, which can be the first presentation of a major systemic illness like IBD, or endophthalmitis, a potentially life-threatening infection. So you can see how "simple, common conditions" can be very severe or complicated.

 

Fine, maybe a RN/NP/PA won't deal with eye complaints. What about a young man with a sore throat? Rapid test for Strep is positive, so he goes home on amoxicillin. But after 5 days, still has fever and sore throat. This could be oral candidiasis, as a result of his HIV that hasn't yet been diagnosed. Or a peri-tonsillar abscess, or Lemierre's syndrome, which can lead to permanent neurologic deficits or death. Or scarlet fever, which can leave him on dialysis for the rest of his life.

 

What if he develops a rash with the antibiotics? Will the RN/NP/PA be able to differentiate a simple drug eruption from Stevens-Johnson syndrome?

 

This is my main problem with the independent practice of NPs and PAs. Medicine is easy and straightforward, until it isn't. And the argument that they will only deal with the common diseases doesn't wash, because you need training to sort out the common from the uncommon, and the differences can be very subtle. 85% of cases are your common benign conditions, but 15% are the rare and life-threatening, and if you can't get the diagnosis, you can't be properly treated.

 

Oh, and all of the alternate diagnoses I mentioned above have been real cases that I've seen in my admittedly brief time practicing. So they come up not infrequently.

[PAstudent]

The problem is not treatment of common illness. Any algorithm can do that. The problem is diagnosis, where many uncommon and potentially life-threatening illnesses have only subtle differences from common benign conditions. Algorithms don't help much here. Another issue is dealing with complications. These are the situations that a residency-trained MD deals with better than an RN/NP/PA.

 

I'll give a common example. Pink eye is usually due to viral conjunctivitis. It's very easy to dismiss patients with red, painful eye complaints as pink eye, and send them home with artificial tears. But you need experience and training to differentiate viral conjunctivitis from glaucoma, which is can lead to permanent loss of vision, iritis, which can be the first presentation of a major systemic illness like IBD, or endophthalmitis, a potentially life-threatening infection. So you can see how "simple, common conditions" can be very severe or complicated.

 

Fine, maybe a RN/NP/PA won't deal with eye complaints. What about a young man with a sore throat? Rapid test for Strep is positive, so he goes home on amoxicillin. But after 5 days, still has fever and sore throat. This could be oral candidiasis, as a result of his HIV that hasn't yet been diagnosed. Or a peri-tonsillar abscess, or Lemierre's syndrome, which can lead to permanent neurologic deficits or death. Or scarlet fever, which can leave him on dialysis for the rest of his life.

 

What if he develops a rash with the antibiotics? Will the RN/NP/PA be able to differentiate a simple drug eruption from Stevens-Johnson syndrome?

 

This is my main problem with the independent practice of NPs and PAs. Medicine is easy and straightforward, until it isn't. And the argument that they will only deal with the common diseases doesn't wash, because you need training to sort out the common from the uncommon, and the differences can be very subtle. 85% of cases are your common benign conditions, but 15% are the rare and life-threatening, and if you can't get the diagnosis, you can't be properly treated.

 

Oh, and all of the alternate diagnoses I mentioned above have been real cases that I've seen in my admittedly brief time practicing. So they come up not infrequently.

 

Please do not lump PAs and NPs together like this. The two are different professions with different training and different roles. This is a thread about nurses/NPs not about PAs. Much of what you have said does not apply to PAs. PAs do NOT want independent practice. That defeats the whole point of the role. PAs are physician-extenders who ALWAYS work under a physician; basically the same way a resident works under a staff physician. A PA is essentially a perpetual resident. When you talked about the need for residency-trained physicians, you are right. And just as a resident learns and practices under supervision, so too does the PA.

[MarathonRunner]

And there are plenty of MDs out there who don't get the diagnosis correct either. Personally, I saw over 5 OB/GYNs and three family doctors before FINALLY seeing one doctor who suggested that I might have endometriosis and that I should have a laparoscopy to diagnose and excise the endometriosis, if found during the laparoscopy. So I spent YEARS (basically from the age of 14 to the age of 25) in CONSTANT pain because no bloody doctor diagnosed the endometriosis until I finally found the one gynaecologist who did! Low and behold, when the surgery was done, I had endometriosis lesions all over the outside of my uterus and all over both ovaries. So no wonder I was in constant pain!

 

So even MDs make plenty of diagnostic mistakes. I spent all those years in enormous amounts of pain because all those doctors dismissed my pain or thought that the pain was "normal" despite the fact that I told them I would be curled up in pain, in the fetal position, during my period, unable to function at all for 3-4 days at a time. Normal? I don't think so.

 

This personal experience of mine is one of the reasons I want to study medicine. I've been a patient who was incredibly poorly treated by physicians for all those years and I am determined to do better.

 

So having an MD isn't a guarantee that someone will get the diagnosis right. And as someone who has unfortunately spent periods of time without a family doctor, I would much rather have a nurse practitioner looking after me than having to spend hours and hours at a time in a walk-in clinic, or even worse, having to spend longer waiting in an ER for a non-emergency, yet still important, medical condition.

 

The problem is not treatment of common illness. Any algorithm can do that. The problem is diagnosis, where many uncommon and potentially life-threatening illnesses have only subtle differences from common benign conditions. Algorithms don't help much here. Another issue is dealing with complications. These are the situations that a residency-trained MD deals with better than an RN/NP/PA.

 

I'll give a common example. Pink eye is usually due to viral conjunctivitis. It's very easy to dismiss patients with red, painful eye complaints as pink eye, and send them home with artificial tears. But you need experience and training to differentiate viral conjunctivitis from glaucoma, which is can lead to permanent loss of vision, iritis, which can be the first presentation of a major systemic illness like IBD, or endophthalmitis, a potentially life-threatening infection. So you can see how "simple, common conditions" can be very severe or complicated.

 

Fine, maybe a RN/NP/PA won't deal with eye complaints. What about a young man with a sore throat? Rapid test for Strep is positive, so he goes home on amoxicillin. But after 5 days, still has fever and sore throat. This could be oral candidiasis, as a result of his HIV that hasn't yet been diagnosed. Or a peri-tonsillar abscess, or Lemierre's syndrome, which can lead to permanent neurologic deficits or death. Or scarlet fever, which can leave him on dialysis for the rest of his life.

 

What if he develops a rash with the antibiotics? Will the RN/NP/PA be able to differentiate a simple drug eruption from Stevens-Johnson syndrome?

 

This is my main problem with the independent practice of NPs and PAs. Medicine is easy and straightforward, until it isn't. And the argument that they will only deal with the common diseases doesn't wash, because you need training to sort out the common from the uncommon, and the differences can be very subtle. 85% of cases are your common benign conditions, but 15% are the rare and life-threatening, and if you can't get the diagnosis, you can't be properly treated.

 

Oh, and all of the alternate diagnoses I mentioned above have been real cases that I've seen in my admittedly brief time practicing. So they come up not infrequently.

[ADH]

Do any of you think that computers will play a big role in meeting the future demands in health care?

 

What I mean is, do you think that there will be some computer system in which you input the patient's current symptoms, and then based on these symptoms plus the patient's health records the computer spits out a list of possible diagnoses with corresponding probability values? The doctor would then just double check that the results and suggested treatment plans are reasonable.

 

Does such a thing already exist?

[BigM]

Do any of you think that computers will play a big role in meeting the future demands in health care?

 

What I mean is, do you think that there will be some computer system in which you input the patient's current symptoms, and then based on these symptoms plus the patient's health records the computer spits out a list of possible diagnoses with corresponding probability values? The doctor would then just double check that the results and suggested treatment plans are reasonable.

 

Does such a thing already exist?

 

There currently are and will be computer systems similar to this. Right now you can put the systems into google and do a search and it will somewhat do this. There's other websites like Up-to-Date which do a better job of this. Ultimately you still need expertise to idenitfy the symptoms, invesitage the possibilities, etc. Physicians won't be replaced by computer anytime in the near future but they will certainly continue to have increasing roles in our practices.

[cheech10]

PAstudent, I agree that MOST PAs do not want independent practices, and have no issue with them. But I HAVE encountered PAs who want to practice independently, although the sentiment is much more frequent with NPs.

 

And MarathonRunner, you're absolutely right, having an MD does not mean you won't make diagnostic errors. But MD training focuses on differential diagnosis, where, in my experience, RN training (the basis for NPs) focuses on following algorithms, policies, and procedures, with less focus on making a diagnosis.

 

ADH, there are clinical prediction rules for various medical conditions that give you a probability of having a certain condition, but they have variable sensitivity and specificity, and are of variable clinical utility. The variability of patient presentations for the same clinical entity makes it difficult for algorithmic diagnosis, which is what a computer would likely use.

[A-Stark]

Any physician that isn't already thinking about a differential while conducting the history hasn't received especially good (or adequate) training. And while computers may have a role in aiding diagnosis and management, algorithms would still require significant "heuristics" (i.e. actual people) to be at all useful.

 

Not sure how this relates to UpToDate - a great tool for background reading, to be sure, and helpful for researching management, but hardly a diagnostic aide.

[Mars_Bound]

I've worked with nurse practitioners in the community setting in Ontario.

 

They get paid around $80,000/year. As far as I know, NPs aren't unionized here (I've talked to a few applicants). I may be wrong though.

 

are you in nursing?

[breathlessrrt]

First off let me say that I am a respiratory therapist (4 yrs of training) then I took another 3 years to become an Anesthesia Assistant. I am thinking about becoming a PA because I am not sure if becoming a doctor is in my cards. I am already 31 years old and would have to do some up grading as my GPA is only 3.3 out of 4.0 (over 4 years) and my AA marks are 3.6/4.0.

 

I know that in New Brunswick PAs are to strictly work under the attending physician much like an AA. Some doctors wants them and other do not as they are scared that they are going to take over. THIS IS NOT WHAT WE WANT!!! I hope for the med students and residents that you can learn to work with PAs as we are here to assist you not take over!!

 

As for nurses ERRRR!! They have to have their hands in every profession. For instance: instead of having a Licensed Registered Respiratory Therapist in the chest clinic teaching about asthma, COPD, OSA etc they hired a nurse and had to send her back to school for 2 years. They even hired a nurse to become the manager in IT services. In NB they removed the respiratory therapist for the flight team and are now just nurses. This is DANGEROUS!! they come to the OR to learn how to intubate (which most of them can't or are horrible at the procedure). Now they ask the RRT to come along for the ride because they are not comfortable with the ventilator or intubating. Furthermore, they are monitoring patients under conscious sedation and giving medications without having ACLS or airway management. As everyone knows BMV is not as easy as it appears.

 

I would love to put a stop to their advancements but how?

[leviathan]

So having an MD isn't a guarantee that someone will get the diagnosis right. And as someone who has unfortunately spent periods of time without a family doctor, I would much rather have a nurse practitioner looking after me than having to spend hours and hours at a time in a walk-in clinic, or even worse, having to spend longer waiting in an ER for a non-emergency, yet still important, medical condition.

On your first point, you're absolutely right that an MD won't guarantee a diagnosis, and I'm sorry it took so long to make that diagnosis. However given the pain and suffering you went through, imagine that suffering at a much larger scale if nurses try to do the job of physicians when they have a fraction of the training, and not even the same kind of training. Nurses spend 2 years learning how to be a nurse (NOT a doctor), and then another couple years at most to be a nurse practitioner, none of those years being anywhere near the intensity of medical school or residency. Physicians spend 4 years in medical school, and then another 2 years of residency learning for 80-100 hours/week.

 

As for your second point, I think nurses and nurse practitioners are a valuable asset to our health care team and are better than someone having no care at all. However, I don't agree with them trying to replace the work of physicians in areas where there aren't health care shortages, and I don't agree with the government's choice to bandaid our medical system by hiring nurse practitioners instead of fixing the problem by training more physicians and providing better incentives to work in underserved regions.

[mrozed]

Any physician that isn't already thinking about a differential while conducting the history hasn't received especially good (or adequate) training. And while computers may have a role in aiding diagnosis and management, algorithms would still require significant "heuristics" (i.e. actual people) to be at all useful.

 

Not sure how this relates to UpToDate - a great tool for background reading, to be sure, and helpful for researching management, but hardly a diagnostic aide.

 

Have you seen IBM's Watson supercomputer roll over Jeopardy! champs Brad Rutter and Ken Jennings? AI is getting pretty sophisticated... autonomous differential diagnosis doesn't seem that far off.