nurse practitioners

[olecranon]

I'm seeing more and more NPs these days in hospitals and in family practice settings essentially assuming the role of a family doc....is this where family medicine/primary care is heading?? Will they become the CNRA's of family medicine?

[coastalslacker]

Absolutely the future.

 

Our family doc isn't very good. But his NP, who my wife always sees, is awesome, so she doesn't want to switch.

[AnotherMedStudent]

Perhaps, that depends on how well your medical association fights for it and how well the College fights for it.

 

Worst comes to worst, a family doctor will get referrals from NPs and become like a specialist.

[HopeToBeGreen]

Aren't NP's going to become to doctors what dental hygienists are to dentists?

 

Doctors will set up shop with 1 or 2 NP's and use it as a way to multiply their income. Doesn't the doctor bill for each procedure the NP does?

[moo]

Fact is, and this is what the CFPC and the respective Colleges and FP provincial associations don't want to admit, is that NPs provide just as quality care as FPs. All this about how FPs will catch the rare diagnosis is bunk. Most FPs refer if there is something they can't figure out and fact is, most NPs will too. There are many horrible FPs out there; If I had a nickel for every time a patient complained about their FP, I could retire today.

 

Studies have shown NPs provide equivalent care to FPs. The only difference is that they take longer and tend to do a more thorough exam.

 

I worked with NPs in the US and in Alberta. In the US, they not only did primary care, they were on the wards, writing orders, essentially functioning as a resident. PAs were also around and were often times 1st surgical assists.

 

Same as for anesthesia, I think CRNAs can be trained to be just as competent as an MD-A's.

[meshuga3]

You know, I don't usually hop on these boards to comment -- more just to read what others have to say (which has been very helpful over the course of my training, I'd add) -- but I feel like I have to say something here. In my opinion, yes, I agree with Moo, and others, that NPs are now, or will be, with expanded training, capable of performing general primary care as well as FMDs. However, as a previous poster has noted, I see this as an opportunity to focus on those rare diagnoses that Moo points out would normally be referrals, or to perform procedures, or to, generally, do more "broad-spectrum" family medicine. I'm going into family medicine, and while I don't relish the idea of doing less bread and butter medicine, I do think that I'll appreciate having the time to spend more time with more complicated patients, or do procedures, or what have you. Now if only payment models could be adopted that would encourage this sort of approach... (e.g. capitation/blended reimbursement).

[Prince Medward]

You know, I don't usually hop on these boards to comment -- more just to read what others have to say (which has been very helpful over the course of my training, I'd add) -- but I feel like I have to say something here. In my opinion, yes, I agree with Moo, and others, that NPs are now, or will be, with expanded training, capable of performing general primary care as well as FMDs. However, as a previous poster has noted, I see this as an opportunity to focus on those rare diagnoses that Moo points out would normally be referrals, or to perform procedures, or to, generally, do more "broad-spectrum" family medicine. I'm going into family medicine, and while I don't relish the idea of doing less bread and butter medicine, I do think that I'll appreciate having the time to spend more time with more complicated patients, or do procedures, or what have you. Now if only payment models could be adopted that would encourage this sort of approach... (e.g. capitation/blended reimbursement).

 

Which procedures do you envision may, in the future, be commonly performed by GPs?

[leviathan]

This is one reason why I'm shying away from family medicine. A lot of family medicine care has guidelines and algorithms that an NP can follow, which when you're looking at large-scale outcome studies, you won't find a difference in outcomes. The problem is, I don't want to be that person that the NP mismanages which leads to morbidity or mortality that is not detectable in an underpowered or improperly designed study. Politicians don't care about that though, nor are they trained to critically analyze literature. NP lobbyists use this to their advantage for sure.

 

I'm fully in support of NPs who are there to address the shortages in health care that we have in our country. They can do an adequate job most of the time. I just don't think they should be working in an area with adequate numbers of FPs because anything that deviates from a perfect bread-and-butter case is beyond their capabilities, and most of them fail to respect that or refer.

 

Maybe it was just a bad experience, but I worked on an OBGYN service in a clinic with midwives and nurse practitioners. They were great at doing the stuff which even I learned how to do in a matter of weeks. Any time a patient had a medical complaint like a headache, nausea, heartburn, etc...they would shrug off their problems and write them prescriptions without doing any workup at all. Their complete lack of knowledge outside of their narrow spectrum of routine care was a bit concerning to me.

[meshuga3]

Re: Procedures. I don't mean anything terribly fancy. I mean more time for derm biopsies, I&Ds, perhaps resetting fractures if your office is capable of handling same-days and has an x-ray suite, or draining effusions (i.e. lower-acuity stuff that doesn't necessarily have to go to the ED), joint injections, that sort of thing. All stuff FMDs are perfectly capable of, but a lot of which may get referred in a very high-throughput practice. And I don't mean just procedures. I mean more time for that, if that's your thing, but also more time for managing your own sick patients in hospital (family medicine isn't just an outpatient specialty), for arranging palliative care for dying patients, for thinking very hard about that elusive rheum or immunologic diagnosis and ordering appropriate tests before referrring onto the specialist.

[moo]

Any time a patient had a medical complaint like a headache, nausea, heartburn, etc...they would shrug off their problems and write them prescriptions without doing any workup at all. Their complete lack of knowledge outside of their narrow spectrum of routine care was a bit concerning to me.

 

Sounds like a lot of family docs in this country.

 

You can do great things in family medicine. Sad thing is, most family docs are exactly as you describe.

 

Not to diss family docs. There are a lot of great ones out there. But it seems like there are also a lot of bad apples; I hear complaints from patients all the time.

 

Your post is bang on though. The rarity of adverse outcomes makes it quite difficult to detect in any study. And NPs know this and use it to their advantage. But in the end, I still say an NP can handle almost everything a family doc can do. Keep in mind that NPs and midlevels are also encroaching on many other fields as well. This is hardly a phenomenon unique to family medicine.

[coastalslacker]

I think our medical association is a venerable eunuch!

 

If you asked a doctor 30 years ago if nurses would be allowed to practice medicine, he'd laugh and shake his head.

 

My oh my how times have changed.... the CMA has failed.

 

We're doctors not for political purposes, not to quell "shortages" or "maldistribution" problems, not to "move the meat", not to engage in masturbatory ivory-tower ethics sessions, and certainly not to abandon our patients to nurses, but to be there for our individual patients. Not for a population of patients. Not for a cohort. For individual patients.

 

The individual patient could not care one iota about how his condition is common or rare. He cares only that the doctor has diagnosed it correctly and whether it can be managed.

 

Nurses do not have the knowledge, training, or intellect to correctly diagnose and manage all patients, even at the most base general level. They should not be allowed to practice medicine at all. Their role is best saved for nursing, which is a strong profession in its own right, but its not medicine.

 

There was significantly less knowledge 30 years ago in ALL fields. A generalist, or, family practioner, could have a reasonably strong knowledge about a relatively wide swath of medicine. That is not possible anymore. While family physicians are still required to have a broad scope, their knowledge has become even more superficial (relative to the knowledge available) because there is so much more to know. It is a hard job. Because of this, algorithms are developed, become standard of care for many common conditions, and then become the modus operandi for many practioners. Why can't a nurse practioner, in concert with a family physician, run through the same algorithms?

 

Physician extenders are used to great benefit in the States. On an orthopaedic elective last year I met a physician assistant who had been working with his group for seven or eight years. I would wager that his knowledge about a highly subspecialized portion of medicine (sub-speciality within ortho) was close to that of someone who had obtained subspeciality fellowship training in that area. Many of the pods had physician assistants who were extremely talented and helpful - by working with the same physician for an extended period of time they basically end up using the same decision making process as their boss - thus they see patients independently and make the right decision, making the practice more efficient. Bright, motivated people learn as they go, and medicine certainly doesn't have a monopoly on bright, motivated people.

 

It's similar to the "difference" between Royal college and CCFP Emerg docs - ie there is no difference once they've been in practice a certain number of years. You put nurse practioners and physician assistants in offices with family physcians and I bet, after several years (I don't know how many) there are fewer differences than many might think. Family medicine isn't rocket surgery. Red flags are red flags and it isn't that hard to learn them. If there's uncertainty, well the NP walks down the hall and asks the MD. Patients want time to talk about their problems and feel heard - great send in the NP and utilize family docs more efficiently. As a clerk I was interested in family medicine, but even at that point in time found much of it so routine and algorithmic that I couldn't imagine doing it long term - checklists of things to go through for diabetic patients when they visit, well child checks etc. Physician extenders provide a relatively cheaper way of getting the same work done at a similar skill level. They also mean we don't need as many family doctors. Effort and caring for one's patient is going to be the difference between a strong general practioner - whether that person is an NP or family MD, I don't think it matters.

 

If your post was in jest (and looking back at it I think there's certainly a good chance it might be), apologies for my sarcasm meter being out of service.

 

At the end of the day self-interest will rule. Anaesthesiologists don't want CRNA's because it threatens their job security. Similarly, family doctors will not welcome in physician extenders not because there's a difference in patient care, but rather because their territory is getting poached. It's a great time to be a family doctor - income relative to other specialities is rising and, by golly, they deserve it because there's a shortage..... At some point government is going to catch on cause we're running out (have run out?) of money. At the risk of sounding smug, I'm really glad I'm a surgeon cause it'll take a lot more effort to phase me out.

[bones]

This topic has been on my mind for some time now, and I've enjoyed reading everyone's posts.

 

Some time ago, I actually did a literature review of the evidence to answer the question "Can experienced nurses (including NPs) replace family physicians?" I will post the papers I reviewed at the end of the message in case anyone is interested in picking apart the data and wetting their Evidence Based Medicine beaks. I wouldn't mind some peeps with EBM skills to have a look at the papers and throw in their 2 cents, since I'm a newb when it comes to all this.

 

The bottom line is this: There are insufficient high-quality studies of sufficient power to fully answer the question of if nurses can replace family physicians. For conditions which have already been diagnosed, as well as for undifferentiated minor illnesses treated in the context of a team consisting of physicians, experienced nurse or nurse practitioner care may result in similar health outcomes as compared to physician care.

 

The studies which showed equivalent or superior care from nurses were in fact not sufficiently powered to assess equivalency (of note, this was pointed out by the authors of the first reference below, who ironically may have a pro-nursing bias in that I think they are advocates for nurse primary care)

 

Having said all this, I think all of this speaks directly to the training of physicians and of family physicians in particular. Perhaps we should take a hard look at how we train physicians, and begin a discourse where we bring more modern perspectives and approaches to learning pathophysiology, anatomy, diagnosis, evidence, etc. etc. I agree that blindly falling back on algorithms for any of our care is dangerous and does a disservice to the years of learning and clinical acumen we've accumulated.

 

And can someone please post a description of the training it takes to become a nurse practitioner (i.e. course work and clinical exposure required)?

 

I have a lot more thoughts on this, but it's late, and I'm tired.

 

 

--------

 

References:

Substitution of doctors by nurses in primary care (Review). Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.

 

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002 Apr 6;324(7341):819-23.

 

Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000 Jan 5;283(1):59-68.

[justletmein]

Just a thought:

If nurses think they can replace FP's, let them pass the CFPC board exam and prove it.

[coastalslacker]

Just a thought:

If nurses think they can replace FP's, let them pass the CFPC board exam and prove it.

 

That's even more dangerous to family physicians - you don't want to do that. I have friends who've written this exam and they report that it's not that tough. NPs CAN do many of the straightforward things that FPs do - I don't think anyone would question that. With specialized training/experience they can do more than straightforward things.

[coastalslacker]

This is a good point. We're trying to fit the ideal of the "family doctor" into our antiquated medical education system (circa >100 years ago, thank you Mr Flexner). Maybe we should be transforming our education system to match the current scope of medical knowledge instead. I know that doing a huge amount of obstetrics in medical school (2 fields involve themselves in obs: obs and GP) while losing exposure and experience in imaging (basically all fields) and anesthesia (most fields) does not correlate well with modern medicine.

 

Depends on what part of medical education you are referring to. I think the goal of undergraduate medical education should be to produce someone with a broad understanding of the various areas of medicine - ie a family physician. 6 weeks of obstetrics and gynecology (what I did in medical school) does not seem unreasonable in the context of a 2 year clerkship. Gynecological issues will be very commonly seen by a generalist and a generalists also (should, for system efficiency's sake) follow women with uncomplicated pregnancies during the first couple trimesters. Really, this should be part of family medicine residency as well.

 

In contrast, the vast majority of family physicians do not look at imaging - they look at the report. If they had more training in imaging would they look at more images? Maybe. But that takes longer. And what if they disagree with the radiology report? Are they going to disregard the report and treat something based on their opinion, or, are they going to go on the opinion of someone who dedicated 5 years of their life to learning to look at imaging and then has done it day in and day out since then? (as a caveat, in ortho we often disregard the report, but we've also dedicated 5 years to specifically looking at our small part of the imaging world and actually understand the treatment implications of what we're looking at).

 

Anaesthesia rotations are probably irrelevant except for future anaesthetists and for learning how to tube a patient if that's something you'll be in a position to do in an emergency. Anyone can do regional anaesthesia if they learn their anatomy.

 

I think undergraduate medical education is pretty good and, from what I've heard, so is post-graduate medical education for family medicine.

[thebouque]

 

In contrast, the vast majority of family physicians do not look at imaging - they look at the report. If they had more training in imaging would they look at more images? Maybe. But that takes longer. And what if they disagree with the radiology report?

 

From my experience, family physicians, whether for inpatient or for ER/oupatients look at chest Xrays, abdominal x rays, and a lot of musculoskeletal x rays (ankles, knees, shoulders, wrists/hands and pelvis). They discharge/treat their patients according to the their own interpretation of the x ray, and if the report says something else they'll do a follow up (which they do most of the time anyway except for those normal chest/abdo x rays). However they don't interpret other kind of imaging.

 

However most ER physicians (fp doing ER, R3s and R5s) are trained in ultrasound now.

 

Peace

[Jochi1543]

 

And can someone please post a description of the training it takes to become a nurse practitioner (i.e. course work and clinical exposure required)?

 

You have to get your RN first (so a 4-yr degree), then practice as an RN for some time - 2 years of full-time work is one number I've heard - before you can enroll into a master's of nursing program. The MN is usually 2-2.5 years and to become an NP, you'd have to pick the "practice" stream - some MNs are coursework only and others have a strong research component, so you have to select the one that's more hands-on in order to be able to register as a nurse practitioner after.

 

 

So basically, it's a combination of a master's degree and significant clinical experience.

 

 

 

ETA: I checked the U of A NP program requirements and it requires 4500 hours of working as an RN - that's about 2.5 years if you work 48 hrs/week and take 1 month of vacation/year.

[cnb88]

You have to get your RN first (so a 4-yr degree), then practice as an RN for some time - 2 years of full-time work is one number I've heard - before you can enroll into a master's of nursing program. The MN is usually 2-2.5 years and to become an NP, you'd have to pick the "practice" stream - some MNs are coursework only and others have a strong research component, so you have to select the one that's more hands-on in order to be able to register as a nurse practitioner after.

 

 

So basically, it's a combination of a master's degree and significant clinical experience.

 

 

 

ETA: I checked the U of A NP program requirements and it requires 4500 hours of working as an RN - that's about 2.5 years if you work 48 hrs/week and take 1 month of vacation/year.

 

This is correct. If you just have an MN though, you aren't a nurse practitioner. You have to do the MN/NP route. There's also a certain number of hours you have to conduct under either a doc directly or nurse prac (not sure of the details) before you're certified to be able to "practice" independently (so kind of like a residency or clerkship). My understanding is that basically the NPs learn JUST what you'd need to know as a family doc. Ie, you wouldn't need to have all the different rotations or necessarily look in depth at certain aspects medicine covers. Also, anatomy/physiology and some pathophysiology is covered in nursing undergrad and to be an RN you have to know many rules of medications (ie normal dosages, routes of administration, etc) just like docs need to (minus their exact mechanism) because nurses have to be able do double check the doctor's orders for errors, and you can't do that if you don't know what prescription X does. Considering after 4 years of nursing and some experience you have some similar knowledge to med students in their first two years (with gaps, obviously), it isn't much of a stretch that in another 2.5-3 you could be able to write SOME prescriptions (NPs aren't able to write out narcotics/benzos and some other meds like that) and know when to hand off to someone more experienced.

 

In rural (and even some underserviced-urban) areas it might be useful to have a system like dentists/dental (hygenists? assistants? I don't really know the difference) have. If it's not a routine case, call in the doc for a quick consult, and done. If they're utilized properly, I can see it benefiting the system as opposed to taking it over...

[NLengr]

Instead of having to utilize nurses to provide primary care, why not just reinstate general licensure?

 

This is a better solution for everyone. Unfortunately the CCFP will fight it tooth and nail.

[Lactic Folly]

In contrast, the vast majority of family physicians do not look at imaging - they look at the report. If they had more training in imaging would they look at more images? Maybe. But that takes longer. And what if they disagree with the radiology report?

 

For primary care providers, it's not so much about looking at images, as it is understanding what to request and when, knowing what info to put on the requisition, being able to tell your patients what to expect during an examination, helping them decipher some of the more technical language in a report, and understanding what factors cause limitations on a study and why (or why a type of study is particularly good for an indication).

[leviathan]

To elaborate further on my last post: If a NP saw a pregnant patient with a headache, her differential was basically the following: pre-eclampsia or non-pre-eclampsia associated headache. She either had pre-eclampsia or she was fine. After ruling out the former, treatment for the latter was esgic.

 

Seriously.

 

This is the kind of thing where yes, the vast majority of these midlevels didn't miss anything bad, not because they were skilled providers, but because 99.9% of the time this population of young healthy pregnant women are going to have some benign primary cause of headache. I'd hate to be that 0.1% of pregnant patients going to this provider with serious pathology and end up being harmed by their negligence. It's that low frequency that also prevents any study from detecting their incompetence, unless you had a trial with tens of thousands of patients...

[leviathan]

Sounds like a lot of family docs in this country.

 

You can do great things in family medicine. Sad thing is, most family docs are exactly as you describe.

 

Not to diss family docs. There are a lot of great ones out there. But it seems like there are also a lot of bad apples; I hear complaints from patients all the time.

I'm assuming any FP would at least do a basic exam and history to rule out come to a working diagnosis and rule out serious problems, unlike the things I have seen midlevels do. I haven't done my family rotation yet though, and I guess even if I do, the type who works in the academic setting will probably not be the type you're describing.

 

Your post is bang on though. The rarity of adverse outcomes makes it quite difficult to detect in any study. And NPs know this and use it to their advantage. But in the end, I still say an NP can handle almost everything a family doc can do. Keep in mind that NPs and midlevels are also encroaching on many other fields as well. This is hardly a phenomenon unique to family medicine.

As I've done my clinical training in the US I have run across midlevels in many specialties. I did cardiac surgery and PAs were first-assist on all the cases. In this direct supervised setting I think they are a great asset and not a liability to patient safety.

[Erk]

The majority of arguments against NPs miss two major things.

 

For one thing, it takes substantially longer to train a NP than it does to train a family doc. 3-4 years med school + 2 years CCFP = 6 years max. To train an NP is 4 years RN training, 2 years MSc, 2 years' minimum work experience. Add to that that very few nurses are interested in the NP line of work and the training it takes, and you have a recipe for a 'trickle in' profession, not a wave influx. Further, a lot of NPs I've heard about are not interested in general practice; they want to continue their work in nursing, in a supervisory role to other nurses with some powers to expedite the job. They are fantastic for this. Nurse practitioners in general practice will not outnumber family docs any time soon (probably not ever) and we already have a shortage of the latter.

 

For another, acting as if a nurse practitioner with six years of direct training and years of experience is somehow unable to perform generalist level diagnosis is ridiculous. Yes, there are diagnoses that NPs will miss; there are diagnoses that family docs miss too. I don't think anyone has any real idea what the comparative rates of error are, but I would be shocked if there was much difference. Medical school is not a magical land where you get super powers, it's just training. Two professionals can come to the same degree of training through different pathways.

[Erk]

I just can't believe there are people within the profession of medicine who support the use of independently-acting nurses for primary care. We've made primary care suck so much as a field that we don't even care if doctors don't do it anymore!

 

What on Earth makes you think that? Family practice is one of my key interests. I'm just not threatened by the idea of working alongside people who got their training through different methods, whether it be nursing school and field experience or a med school in south africa.

[leviathan]

As much as this new troll is, well, trolling...he has a point. 4 years of nursing school is not the same as 4 years of medical school. The focus of training is very different, and there is only some small overlap. The actual volume of material covered in nursing school is also not anywhere near as intense as medical school. To say that spending 2 years working as a nurse counts towards more years of education is also stretching it. If I worked in the hospital drawing blood for 20 years does that mean I have more training than a family doctor and can work in that job role?

 

I hate these nurse vs MD threads that always start up in here. They are 2 very different professions that happen to both treat patients, and nursing is a very respectable job. It's just silly to think that a nurse is like a Doctor-Lite and with a few extra years of training they can upgrade to Doctor status. To do that would require attending medical school.

 

If you think NPs have adequate knowledge and provide safe care then go to med school and then spend a week with one and see how much of a knowledge gap really exists. They are a great addition when no MD is available to a patient in remote nursing stations and the like, as they will still make a huge impact on the health of that community even if they miss something once in awhile.