nurse practitioners

[ploughboy]

Honestly, I can't fully understand why RNs would become NPs only to do housestaff work on inpatient wards on an interminable basis. One nice thing about moving beyond residency - or even just the PGY1 level - is having underlings to do your scut work for you. Yet NPs end up doing lots of dictations and notes and social work consults and gods-know-what-else kind of monotonous paperwork.

 

Better pay, better hours, no overnights, more prestige (ie you get to boss around your former co-workers...seriously, get a bunch of floor nurses together over a ward pot-luck, subtly turn the conversation toward nursing managers and NPs and watch the claws come out!)

[ploughboy]

I don't care so much about NPs because they at least are not quacks.

 

What bothers me is that the provinces are giving prescribing rights, and lab test ordering rights to naturopaths. They are essentially equating naturopaths to primary care providers and legitimizing their profession...

 

Should I not have billed the provincial medical agency for realigning my patient's chakra, selling him a harmonic crystal and giving him a few drops of a 30C dilution of milkweed?

 

Sorry. My bad. I can still bill for the contactless Reiki, right?

 

[moo]

My friend who's finishing his cards fellowship in the US once told me one group of practitioners thinks from the top down. the other from the bottom up. I'll leave it to you to decide which group is which.

[leviathan]

I feel like you are being unfair by generalizing this ONE incident as being a reflection of the competence of EVERY NP/other mid-level out there. As an example, I saw a younger adult female who had had CONSTANT heavy vaginal bleeding for 3 years straight (! esp. for the ladies here). Her GP's only investigation during those 3 years? Pap smear. But I don't think that we should make a broad generalization about ALL GPs being incompetent and unable to think of anything other than cervical cancer as a cause for vaginal bleeding just based on this one incident.

My bad, I didn't mean it to come off as if I had just seen one incident. There were endless incidents from multiple NPs..pretty much every encounter where they had a problem that wasn't directly in their niche, they would usually just shrug off their complaints, as for whatever reason they just assumed everything was fine and there was no need to consult an MD. I just used the headache as an example, and apparently most people didn't think anything was wrong with it anyway. But kinda what ploughboy was saying, even if an MD doesnt do a thorough workup, s/he at least still considered everything in the differential and decided they were too unlikely to need any further questioning or physical exam or investigations.

[A-Stark]

Fairly good pay, reasonable hours as they do away with the shiftwork, and no call. So they're doing resident work but get made much more and get to leave work at a fixed time.

 

Better pay, better hours, no overnights, more prestige (ie you get to boss around your former co-workers...seriously, get a bunch of floor nurses together over a ward pot-luck, subtly turn the conversation toward nursing managers and NPs and watch the claws come out!)

 

Well, sometimes they leave work at a fixed time; other times they're still finishing dictations at 6:30. I suppose from my perspective I just find floor work so unsatisfying sometimes that I cannot for a second imagine doing it as a more-or-less permanent career. Or maybe I'm just bitter that 75% of my electives up until last week consisted of scut.

 

And this is the crux of my concern about NPs. In my limited experience, NPs are always for the algorithm, follow the algorithm, always the algorithm.

 

And in general, it works. But occasionally that young healthy person with new onset back pain *won't* have simple mechanical back pain, and you at at least need to have thought about a malignancy, or an abscess, or CE, or ank spond or, or, or... If it's not in your world-view, if you don't think about it, then you'll never see it.

 

The standard of care is in any situation is not "perfection", but is what a reasonable physician would do in the same clinical situation. The sense that I have gotten in my admittedly limited interaction with midlevels is that their thought process is different from that of a physician, likely because their training is different from that of a physician, and that they sometimes don't know what they don't know. I'm not saying that to be a jerk...it's just an observation. I often still don't know what I don't know, but the difference is that I don't have a licence yet.

 

I'm midway through a 5-year residency and the amount of stuff that I should know but don't know is frightening. It's not because I'm stupid or lazy (although I am both), it's because there is a vast amount of knowledge that an independent practitioner needs to know in order to be both safe and effective. I remain unconvinced that NP education is sufficient to the task.

 

Maybe I'm being swayed by overhearing a few case presentations by NP students to a specific NP preceptor, where I've sat there thinking "Any staff doc here would be pimping the bejezus out of me on this case, but she's lobbing you soft-ball questions and you're still only getting half of them..."

 

Sorry, ranting.

 

Agreed. And I think my BRBPR with abdo pain is a good example. The NP decided that the patient had an "acute abdomen" yet I wonder just how many times she'd seen the first presentation of just that. I doubt she'd ever done anything resembling a general surgery consult in emerg, and she certainly didn't appropriately examine the patient before rushing forward with expensive imaging - and in the absence of a differential.

 

My first thought was that - while it could just be hemorrhoids - the DRE was absolutely required as the "next best step" in the examination. She could well have had a low rectal cancer that could be readily palpable and, in any case, not be well visualized on CT. That she ended up having "florid" sigmoid diverticulosis wasn't unexpected either, but I never got the sense of an organized approach to this presentation. The NP was certainly "thorough" after a fashion, but the whole thing struck me as overrating the severity of the situation while failing to examine much less look at the putative source of bleeding. Interestingly, I have read before (somewhere anyway) that NPs tend to be more costly for the system as they are more prone to order investigations. I wonder - do they ask themselves how it will change the management whenever they do so?

[leviathan]

- the DRE was absolutely required as the "next best step" in the examination.

Sounds like a USMLE step 2 / MCCQE question.

[bones]

Do family physicians need to be better trained and better equipped to handle the realities of 21st century medicine? Yes. Does this mean that a lazy/ignorant family physician's practice may resemble the practice of a nurse practitioner? Yes.

 

Does this mean that family physicians could reasonably be replaced by one or more nurse practitioners, in the current model of health care, with a result of better patient outcomes and saved money for the system? I believe the answer is No.

 

I'm surprised no one has discussed the fact that the NP curriculum doesn't seem to include topics in clinically-relevant anatomy, or dedicated time seeing patients with the aim of formulating differential diagnoses/treatments and managing follow-ups, or getting exposed to the vast array of medical and surgical specialities - all of which, according to our present understanding - are vital to successful primary care practice where you see undifferentiated, potentially complex, psycho-socially challenged, multi-aged patients.

 

I'm also surprised no one has discussed the issue of ultimate responsibility of patients or acceptance of liability for patient outcomes. Would an NP, as currently trained, accept responsibility and liability for every single family practice patient seen in the course of a clinic day, or on the wards, or in the nursing home, or in emerg (all places family docs commonly practice)? The buck stops with physicians, in all aspects and matters pertaining to the health of our patients. Society gives physicians incredible opportunities and trust, with the understanding that we will put our necks on the line with every single patient we see. Would a nurse practitioner feel comfortable doing the same?

 

It would be interesting to hear from actual nurse practitioners or those training to be one, and to see what they think about wanting to become independent primary care practitioners. I have no doubt there is a strong lobby pushing for this, but I wonder if this is a vocal minority?

[ghost dog]

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.

 

You may (or may not) be very suprised at the amount of clinical / hands on training that NPs get during their 2 year "residencies". The typical amount is usually that of around 700 hours, which amounts to about 4 months.

 

How much does a family medicine resident get ?

 

Not counting on call time: at least 4000 hours (it's obviously significantly more, when call is included).

 

As you can see, it is ridiculous to compare noctors with a family physician's training.

 

I conducted a little experiment at SDN. I asked the Noctors to answer the following question for me:

 

"A 14 yr old comes in with a sore throat and no cough.

 

On exam : T = 37 degrees C. No cervical LTathy and no tonsillar exudate. Ears and chest normal.

 

What is the most likely diagnosis ?

 

What is your treatment ?

 

What guideline would you like to follow?"

 

The guideline in question was obviouslty the Centor / sore throat score. Nobody could answer the above question.

 

All I got were fire and brimstone replies: this is ridiculous, are you really a doctor, etc. etc. Noctors are a joke.

[ghost dog]

Late breaking news: Nurse quacktioners, practicing independently, kill multiple patients with opioid overdoses.

 

story: http://seattletimes.nwsource.com/html/localnews/2017000915_silent13.html

[Jochi1543]

I conducted a little experiment at SDN. I asked the Noctors to answer the following question for me:

 

"A 14 yr old comes in with a sore throat and no cough.

 

On exam : T = 37 degrees C. No cervical LTathy and no tonsillar exudate. Ears and chest normal.

 

What is the most likely diagnosis ?

 

What is your treatment ?

 

What guideline would you like to follow?"

 

The guideline in question was obviouslty the Centor / sore throat score. Nobody could answer the above question.

 

All I got were fire and brimstone replies: this is ridiculous, are you really a doctor, etc. etc. Noctors are a joke.

FML. I had these guidelines pounded into me on Urban FM and then my Rural FM preceptor made fun of me (in a nice way!) and proceeded to swab every single person who I said I wouldn't swab based on the criteria and like 80% of them ended up testing positive. PWND.

[thebouque]

FML. I had these guidelines pounded into me on Urban FM and then my Rural FM preceptor made fun of me (in a nice way!) and proceeded to swab every single person who I said I wouldn't swab based on the criteria and like 80% of them ended up testing positive. PWND.

 

You can be a carrier that doesn't mean you have strep throat.

 

Also Ghost dog could you send us the link to that hilarious SDN thread?

 

Peace

[ghost dog]

You can be a carrier that doesn't mean you have strep throat.

 

Also Ghost dog could you send us the link to that hilarious SDN thread?

 

Peace

 

What the heck ???!

 

No response to the multiple opioid related deaths at the hands of nurse quacktioners?

[ghost dog]

FML. I had these guidelines pounded into me on Urban FM and then my Rural FM preceptor made fun of me (in a nice way!) and proceeded to swab every single person who I said I wouldn't swab based on the criteria and like 80% of them ended up testing positive. PWND.

 

Was your preceptor a nurse quacktioner ?

 

http://www.aafp.org/afp/2009/0301/p383.html

[Baldwin]

well...

the nursing is good for the public service ....

so its good job for a female candidate ....

[ghost dog]

well...

the nursing is good for the public service ....

so its good job for a female candidate ....

 

Nursing as a profession is great. We need all the nurses we can get.

 

Nurse Practitioners practicing independently without supervision.... not so much. This doesn't turn out so well for patients , unless you consider death a desirable outcome (as per the chronic pain / euthanasia clinic in Vancouver).

 

A good job for a female candidate ? I hear women have been going into medicine recently (it's true).

[lostintime]

Another thing I find annoying some people with limited training, and often NP's in particular is blowing off something as "impossible" when in fact it's false and it IS possible, just rare.

 

Because guess what? Even if something is RARE, when there have been case studies published before, that means the patient, including even your family member or yourself could be people it COULD happen to, just not likely to happen to. Communication is kind of important there. Instead of telling the patient, "That's impossible! I've never seen a case in my career" (yeah their 2 year NP career and who knows how long RN career) versus someone experienced who would say "Oh I don't think it's that. It's too unlikely, let's just take a wait and see approach first and if we're still really concerned, then maybe we'll consider it down the road." Seriously, I think it's just stupid when people try to use anecdotal examples instead of evidence-based. Yeah experience is gold, but maybe you were working with specific populations, etc. Can't just generalize based on your own experiences.

[thebouque]

^Physicians do that all the time

[ghost dog]

You're correct. Physicians do do that all the time.

 

As for opinions and experience not being evidence based, well that's the nature of the field of medicine. It is espeically true for things that are rare. Anecdotally I would say that most of what we do is not dictated by evidence but by tradition, policy, and legal protection (surgical scrub; examiner is always on the patient's right side; etc.) Doing things based on those concepts rather than on evidence cannot be generalized to be worse or better.

 

EBM is a great ideal, but it is an extremely flawed ideal. In fact I would argue that it oftentimes does not fulfill the scientific criterion of reproducibility. Furthermore, it cannot do very much to help patients with rare problems.

 

Not quite sure what your point is here.

 

Medicine is changing ; evidence based medicine is becoming the landscape for clinical practice.

 

As for experience, I would hope that a doctor with more of it would incorporate such into their practice.

 

In regards to rare clinical phenomena , I think that is complete crap. Identifying the red flags for back pain comes to mind as an example. The rarity of causa equina versus acute mech back pain?

 

CES is damned rare versus acute mech LBP.

[lostintime]

Yeah it's rare and fine until someone with cauda equina gets missed and paralyzed. I've done tons of follow-up clinics where everyone is "all fine" and seriously a non-medical person could almost come and do those visits. It's when something's wrong that you have to know what to do or when there's a new consult with an actual new issue.

[moo]

But the thing is, even docs can miss things.

 

I had a 18 year old kid come in once with a fever for a few days. That's it. Everything on exam was normal, no murmurs, nothing. I got a CBC initially and the WBC was like 10.7 with neutrophils of about 8.5, nothing spectacular. ALT normal. Mono negative. Then I get a call from a doc at his university health center in another city a month later saying he still had a fever. The doc said he just ordered a CBC, LFTs and some other rheumatologic blood work. Only thing was a a WBC of 18 and a preponderance of neutrophils. I told the doc to get a blood culture as well, as he hadn't ordered one, and cultures were positive 2/2 for strep viridans. He went to the hospital, turns out he had endocarditis. Had a bicuspid aortic valve and needed surgery. (The second doc, presumably had not heard a murmur either or did not do a CV exam.)

 

My point is, I don't think any physician would've done anything differently that I did, yet I missed a bacterial endocarditis. You will miss things in practice, even if you follow routine "standard of care". I'm not going to get a blood culture on everyone that walks in with a fever with no focus (unless there is a clear reason for it--IVDU, or some other reason). But this kid was clean, nothing to make me suspect anything.

[bloh]

But the thing is, even docs can miss things.

 

I had a 18 year old kid come in once with a fever for a few days. That's it. Everything on exam was normal, no murmurs, nothing. I got a CBC initially and the WBC was like 10.7 with neutrophils of about 8.5, nothing spectacular. ALT normal. Mono negative. Then I get a call from a doc at his university health center in another city a month later saying he still had a fever. The doc said he just ordered a CBC, LFTs and some other rheumatologic blood work. Only thing was a a WBC of 18 and a preponderance of neutrophils. I told the doc to get a blood culture as well, as he hadn't ordered one, and cultures were positive 2/2 for strep viridans. He went to the hospital, turns out he had endocarditis. Had a bicuspid aortic valve and needed surgery. (The second doc, presumably had not heard a murmur either or did not do a CV exam.)

 

My point is, I don't think any physician would've done anything differently that I did, yet I missed a bacterial endocarditis. You will miss things in practice, even if you follow routine "standard of care". I'm not going to get a blood culture on everyone that walks in with a fever with no focus (unless there is a clear reason for it--IVDU, or some other reason). But this kid was clean, nothing to make me suspect anything.

 

That's really a bad example because you didn't technically miss anything. You were following a reasonable protocol. Now, had that person come back a week later with the same unresolved fever, with you not doing anything then I'd say you missed the boat. You would have probably been puzzled enough to do further investigations and I doubt an average NP would have blinked an eye.

[moo]

That's really a bad example because you didn't technically miss anything. You were following a reasonable protocol. Now, had that person come back a week later with the same unresolved fever, with you not doing anything then I'd say you missed the boat. You would have probably been puzzled enough to do further investigations and I doubt an average NP would have blinked an eye.

 

But that's exactly it! It was a reasonable protocol, standard of practice, for all primary care providers. I did miss something, something that was quite rare. The implication is that physicians won't miss things like that. Maybe I missed a murmur, I don't know, can't second guess myself now. All I know is that docs do miss things too. I'm ok with people saying NPs shouldn't do primary care or CRNAs shouldn't do anesthesia because it's not cost effective, or if they provide poorer care, etc. But I don't think missing rare things should be a reason we cite, precisely because docs miss rare things all the time.

 

I can think of numerous other examples where their doctor just brushed the patient off and did not bother to investigate things. I saw another parkison's patient who came in for walk in one day complaining of fatigue for several months. Her FMD told her it was due to her PD. Her neurologist told her it was due to her PD. I did some BW on her and her LFTs were way up. U/s showed a ?pancreatic mass and CT essentially confirmed this. SHe ended up dying within a few weeks, but it is unlikely that even if she had gotten this diagnosed earlier it would've made a difference, but the two docs prior to me seeing her DID miss this too. Now substitute NP for FMD and people would be all up in arms about NPs not being competent.

 

I'm not saying that NPs should be taking over our jobs. I do think NPs have a role in our health care system. I think NPs are fine for doing diabetes teaching and managing chronic diseases. They should even be allowed to do walk in clinics under the supervision of a MD (kind of like a perpetual resident) or do nursing home stuff. I do not think they should be team leaders in any sort of setting though.

[thebouque]

That's really a bad example because you didn't technically miss anything. You were following a reasonable protocol. Now, had that person come back a week later with the same unresolved fever, with you not doing anything then I'd say you missed the boat. You would have probably been puzzled enough to do further investigations and I doubt an average NP would have blinked an eye.

 

What makes you doubt that? Your doubt certainly isn't evidence based!

[bloh]

What makes you doubt that? Your doubt certainly isn't evidence based!

 

Fair enough, there may be no such evidence; I haven't looked for any but I just presume that'd be the case. The first 2 pre-clinical years in medschool are all about teaching students on how to come up with a differential and how to think from that point of view. This philosophy then sets you up to think and learn medicine from that point of view. I'd wager that training that NPs receive isn't as robust as those of MDs and there's also the old saying that "you can't teach an old dog new tricks".

[ghost dog]

But the thing is, even docs can miss things.

 

I had a 18 year old kid come in once with a fever for a few days. That's it. Everything on exam was normal, no murmurs, nothing. I got a CBC initially and the WBC was like 10.7 with neutrophils of about 8.5, nothing spectacular. ALT normal. Mono negative. Then I get a call from a doc at his university health center in another city a month later saying he still had a fever. The doc said he just ordered a CBC, LFTs and some other rheumatologic blood work. Only thing was a a WBC of 18 and a preponderance of neutrophils. I told the doc to get a blood culture as well, as he hadn't ordered one, and cultures were positive 2/2 for strep viridans. He went to the hospital, turns out he had endocarditis. Had a bicuspid aortic valve and needed surgery. (The second doc, presumably had not heard a murmur either or did not do a CV exam.)

 

My point is, I don't think any physician would've done anything differently that I did, yet I missed a bacterial endocarditis. You will miss things in practice, even if you follow routine "standard of care". I'm not going to get a blood culture on everyone that walks in with a fever with no focus (unless there is a clear reason for it--IVDU, or some other reason). But this kid was clean, nothing to make me suspect anything.

 

Ah, you didn't miss anything that you know of - there was a case in dialogue with a patient presenting with subtle endocarditis.

 

Had this 18 yr old been to the dentist recently ? Did you ask about this ? No ones perfect - but the lawyer's expect us to be.

 

I would post the dialogue case, but I can't access it on the web. Check it out - it's an interesting case.

 

I had a similiar case a few years ago, and the pt ended up needing a prosthetic valve.