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re: Defeat the Nurse Practitioner scope of practice expansion - Louisiana SB 187
Posted on 4/10/16 at 8:48 pm to guttata
Posted on 4/10/16 at 8:48 pm to guttata
Again yall are using the example of an established NP that has learned alot over the years not only from her experience but also knowledge passed on to her from the doctors she works with. No doubt she is probably excellent and I would see her myself for something minor.
Put aside your bias for a second and realize all I am saying is that there should be some sort of oversight for a NP before they are off on their own. Make them work under a doctor for 2 years (like a mini residency), make them do more years of clinical work with supervision before they graduate, whatever, just make sure someone with a significant amount of experience is overseeing them for a significant amount of time.
This is how medicine works. Ask any doctor and they will tell you they learned 90% of how they practice during their residency working under older doctors who passed knowledge onto them.
Otherwise you won't have NPs like your wife, and the profession as a whole will suffer for it. You will have a certain amount of wackos that want to play doctor that go to nursing school then NP schools that want to crank out graduates that are out on their own with no oversight in the real world
Put aside your bias for a second and realize all I am saying is that there should be some sort of oversight for a NP before they are off on their own. Make them work under a doctor for 2 years (like a mini residency), make them do more years of clinical work with supervision before they graduate, whatever, just make sure someone with a significant amount of experience is overseeing them for a significant amount of time.
This is how medicine works. Ask any doctor and they will tell you they learned 90% of how they practice during their residency working under older doctors who passed knowledge onto them.
Otherwise you won't have NPs like your wife, and the profession as a whole will suffer for it. You will have a certain amount of wackos that want to play doctor that go to nursing school then NP schools that want to crank out graduates that are out on their own with no oversight in the real world
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Posted on 4/10/16 at 8:51 pm to bubbz
quote:
While my mother is probably the exception the rule, I can assure you, she has more hours logged in her particular area than any med student would in all combined years of med school due to her experience prior to being in NP school.
While that makes her a well trained nurse, it does not make her a doctor. And this is not a NP hate thread although we veered off course there for a bit. It's about whether or not they should practice without a supervising physician. We're in no way saying mid-levels shouldn't see pt's and that they don't serve a role. I think we all agree on that. The legislation is basically removing all restrictions on their practice and making them doctors....which they are not. And they were never intended to be and their training is not designed for. How is this so hard to understand?
Posted on 4/10/16 at 8:57 pm to guttata
After reading most of this thread, here's my 2 cents:
1. Why doesn't the AMA allow more medical schools to open up in the US? That would increase physician populations and access to care while, under the law of supply and demand, decrease patient costs and decrease medical education costs.
2. To many, nurses as a group seem more emotionally intelligent than medical doctors. If docs as a group improve their bedside manner, patients will like them more and, for example, be more likely to head their advice. If the patient feels heard, she is more likely to listen...
3. It's flat absurd to say that malpractice premium costs materially contribute to exorbitantly high costs of healthcare. In the 1970s, the legislature, with the approval of physicians, capped liability at $500K. That's a good deal, and the amount hasn't increased at all since then. Many other professionals carry over $1,000,000 in errors and omissions insurance.
4. I'm against FNPs not having to be supervised by a medical doctor.
1. Why doesn't the AMA allow more medical schools to open up in the US? That would increase physician populations and access to care while, under the law of supply and demand, decrease patient costs and decrease medical education costs.
2. To many, nurses as a group seem more emotionally intelligent than medical doctors. If docs as a group improve their bedside manner, patients will like them more and, for example, be more likely to head their advice. If the patient feels heard, she is more likely to listen...
3. It's flat absurd to say that malpractice premium costs materially contribute to exorbitantly high costs of healthcare. In the 1970s, the legislature, with the approval of physicians, capped liability at $500K. That's a good deal, and the amount hasn't increased at all since then. Many other professionals carry over $1,000,000 in errors and omissions insurance.
4. I'm against FNPs not having to be supervised by a medical doctor.
This post was edited on 4/10/16 at 8:58 pm
Posted on 4/10/16 at 9:18 pm to SaintsTiger
What do you think opening more med schools is going to do? It will allow less qualified applicants the ability to get into med school which, in turn, will water down the med school degree. I highly doubt, that if you were to ask the specialists (cause make no mistake, if more med schools opened, there would definitely be more specialists out there, the students wouldn't be going into family practice), do you feel there needs to be more specialists in your area, the majority would not be thrilled about that. I'm sure there are exceptions, but I doubt the urologists of BR think it would be a great idea if BR were to add 4-5 new urologists to the area every year. Maybe med schools should come up with a separate, fast track school, that only takes family practice candidates.
Posted on 4/10/16 at 9:23 pm to SaintsTiger
quote:
Why doesn't the AMA allow more medical schools to open up in the US?
More schools are opening. The number of residency spots has stayed constant for the last 40 years. the biggest problem is finding people to do primary care in "undesirable" places. If you're not from Leesville, it doesn't matter how many medical school or residency spots there are- you're not signing a job offer in primary care in Leesville. Same thing with El Dorado, Arkansas, and you-pick-the-name Nevada.
quote:
To many, nurses as a group seem more emotionally intelligent than medical doctors.
This seems like another good reason for the team approach. Are you suggesting that the conceived general emotional intelligence of nurses drives patients to want to see nurses and not physicians, specifically APRNs without physician oversight?
That said, this is a common topic in most of the primary care fields + AMA journals, and medscape headlines. The current generation in medical school/residency has been beaten upside the head with listen, care, hug, touch, etc.
Not an attempt to brag, but I've frequently been commented on my bedside manner. I don't think it's any better than any of my colleagues- I think that what's being produced now from my schooling and current training is just miles ahead of what "good ol' docs" had or cared about.
quote:
3. It's flat absurd to say that malpractice premium costs materially contribute to exorbitantly high costs of healthcare
Fortunately, I haven't had to look at the numbers yet. But malpractice is something on the physician side that usually comes out of what would have been salary. Again, physician salary is a thin slice of the pie. Defensive medicine, however, is ruining medicine. The concern of lawsuit from "missing" something leads to relatively inappropriate admissions to the hospital as well as unnecessary tests and imaging. So in a way, the fear of litigation leads to less discretion on the part of the physician, regardless of the cost of the insurance or the maximum fine- the fear of being named in a lawsuit/losing would be damaging to a reputation and future ability to provide care. It's a relatively poor excuse. And I thought to myself, "that's dumb- I'll never do something unnecessary because of that," but that's something that is far easier to say than practice.
quote:
4. I'm against FNPs not having to be supervised by a medical doctor.
As currently proposed, me too. But again, with an extensive training program, essentially an NP "residency," where they're trained much more intensely by physicians, I don't think it's totally unreasonable. I think the system is better as is, but depending on how the aforementioned would be setup, I could see myself in favor of it.
The practice I plan to join currently employs an NP. She's very good at what she does. But she wouldn't be comfortable without the MD to lean on when she needs and rightfully so- she hasn't seen nearly as many patients or logged nearly as many hours as a residency graduate.
Posted on 4/10/16 at 9:24 pm to guttata
I think part of the answer is to improve Family Medicine training. The more we can do, along with our practitioners, the better. The specialists will get pissed, but what they will be losing are the easier things we an do that is essentially a waste of their training. Just as NP's are trained to do the easier more straight forward portions of our pt visits/complaints. The whole system needs to widen at the base. If primary care would do more, like they used to, we would need fewer specialists. Then you would see costs come down. Too many people self refer or are referred by their PCP's to subspecialists to things we should be handling. However, reimbursement would have to increase. Honestly, people follow the money.
Hell, the whole system is screwed. Truthfully, we probably just need to burn the whole thing to the ground and start over from scratch.
Hell, the whole system is screwed. Truthfully, we probably just need to burn the whole thing to the ground and start over from scratch.
Posted on 4/10/16 at 9:25 pm to guttata
quote:
Maybe med schools should come up with a separate, fast track school, that only takes family practice candidates.
Not a bad idea. They could cut out 4th year of medical school which is mostly a waste. Would also cut down on student debt. But you still need to create more residency spots for them. These are the kind of ideas we need
Posted on 4/10/16 at 9:27 pm to guttata
quote:
What do you think opening more med schools is going to do? It will allow less qualified applicants the ability to get into med school which, in turn, will water down the med school degree. I highly doubt, that if you were to ask the specialists (cause make no mistake, if more med schools opened, there would definitely be more specialists out there, the students wouldn't be going into family practice), do you feel there needs to be more specialists in your area, the majority would not be thrilled about that. I'm sure there are exceptions, but I doubt the urologists of BR think it would be a great idea if BR were to add 4-5 new urologists to the area every year. Maybe med schools should come up with a separate, fast track school, that only takes family practice candidates.
You're somewhat confusing increased medical school spots with an increase in residency spots. A new Med school doesn't mean 4-5 new urologists per class. It means (whatever the graduating class size is) new US grads applying for new residency spots.
There were plans for a 30-40 student, 3-year fast-track Med school program in Lafayette leading into, if I remember correctly, Medicine, Peds, Family, and OB. OB may not have been present, but the other fields sure were. FM isn't the only path to primary care.
Posted on 4/10/16 at 9:30 pm to SmackoverHawg
quote:
I think part of the answer is to improve Family Medicine training
There's still plenty of great programs out there from when I was looking a year ago. I think the real problem is that most people seem to view it as a good lifestyle field- 9-5 outpatient only, no one under the age of 2, limited procedures.
Like I said before- it's bimodal. There's FM docs that like doing everything, and there's FM docs that like doing nothing. The former are some of the best docs you'll ever meet. The latter are some of the worst.
Posted on 4/10/16 at 9:38 pm to Hopeful Doc
quote:
There's FM docs that like doing everything
That's what the pt's want as well. The unfortunate thing is that it is a unique field that is easy to be terrible at and get by. Yet, also incredibly difficult to be good at due to the vast amount of issues we have to deal with. And if you do all those things we are trained to, and the procedures we are qualified to do and do them all well, the money takes care of itself and you can do quite well. I think a mentoring program of some sort would help. Successful family doc's could show the younger ones how it's done and help ensure their success. Unfortunately, I haven't had anyone to mentor except NP's. And this isn't a insult to my NP's. It's commentary on the fact that no one wants to do primary care due to some major misconceptions and poor examples they've seen.
Posted on 4/10/16 at 9:42 pm to Hopeful Doc
quote:
Hopeful Doc
You sound like you have the right outlook to succeed. Don't be afraid to expand your scope of practice. What's good for one is good for all. Wouldn't mind having a beer with you sometime. Or anyone else on here whether you like me or not.
I never refuse a chance to talk a lot or a heated debate. 
Posted on 4/10/16 at 9:43 pm to SmackoverHawg
quote:
And if you do all those things we are trained to, and the procedures we are qualified to do and do them all well, the money takes care of itself
I've seen some FM salaries that I didn't believe from folks who like to "do it all." From the sounds of it (and from previous posts of yours where, if I remember correctly, you quit seeing hospital patients and scoping because it was less productive than your clinic), you probably laugh at the guy who said "I can't afford to make $200,000/yr"
Posted on 4/10/16 at 9:50 pm to SmackoverHawg
quote:
Wouldn't mind having a beer with you sometime
I may actually be headed to Hot Springs in May.
And I get fussed at for what I try to do sometimes. I had a guy with a leg abscess, likely a brown recluse bite. Happens to be an uncontrolled diabetic. I told my program director who was percepting that day i think I should do a little sharp debridement. He said, "nah, you dont need to be digging around on a diabetics ulcer. Send it off to wound care." I otherwise make it a point to send someone off to a specialist essentially only if they need a procedure. I rarely get a note back from a referral with much more of a work up than was already done. I try to make it to the limits of what we can possibly do before getting someone else involved. I'll wind up practicing in a place almost as subspecialty-barren as you one day, if everything goes my way.
Posted on 4/10/16 at 9:51 pm to LATigerdoc
quote:
Nursing school is simply NOT equivalent education to medical school
Correct.
But Pharmacy School is. And pharmacists should have primary care status.
Posted on 4/10/16 at 9:56 pm to Hopeful Doc
quote:
I've seen some FM salaries that I didn't believe from folks who like to "do it all." From the sounds of it (and from previous posts of yours where, if I remember correctly, you quit seeing hospital patients and scoping because it was less productive than your clinic), you probably laugh at the guy who said "I can't afford to make $200,000/yr"
I would say he's misinformed. If you do it well, the sky is the limit. And I mean legally.
I've told my NP's the same. But the only way to do it is busting arse and taking care of people. I ran into an old doc that I knew when I was little. He was stopping by to see all the renovations and additions at my clinic and reminded me, "See, if you do what you're trained to do, do it well, and take care of the pt FIRST, everything else falls in place." There is a tendency to get caught up in dollars and cents due to the business like nature of medicine now. But periodically I have to bitch slap myself and remind me to focus on patient care and service first and foremost. Then worry about the money. I'll be damned. When I forget about the money for awhile and check...it's there with lots of friends. Like I said earlier, I can be a real dick on here sometimes, but IRL I take care of my pt's, I go above and beyond, and they love me and I love them...for the most part. I think I'm getting a little drunk and rambling, but When I go, I want to be that old arse country doc that everyone loved and no one can replace. And to train the next in line. Our practice has been here since 1954. I feel an obligation to this community and area to grow in and make sure it's here in 60 more years.Posted on 4/10/16 at 9:59 pm to Hopeful Doc
quote:
You're somewhat confusing increased medical school spots with an increase in residency spots. A new Med school doesn't mean 4-5 new urologists per class. It means (whatever the graduating class size is) new US grads applying for new residency spots.
That makes sense. That said, I have an old friend who went to the Caribbean for medical school because he couldn't get in to LSU. He had a GPA well over 3.5 and a reasonable but not great MCAT score. He's now practicing in a community hospital in his hometown parish of Ascension. As far as I know he's doing well there. Not sure why it's good policy for people like him to have to go offshore for training when there will be jobs ready and waiting once the credentials are obtained.
quote:
There were plans for a 30-40 student, 3-year fast-track Med school program in Lafayette leading into, if I remember correctly, Medicine, Peds, Family, and OB. OB may not have been present, but the other fields sure were. FM isn't the only path to primary care.
Sounds like a great idea to me.
Posted on 4/10/16 at 10:00 pm to Hopeful Doc
quote:
I may actually be headed to Hot Springs in May. And I get fussed at for what I try to do sometimes. I had a guy with a leg abscess, likely a brown recluse bite. Happens to be an uncontrolled diabetic. I told my program director who was percepting that day i think I should do a little sharp debridement. He said, "nah, you dont need to be digging around on a diabetics ulcer. Send it off to wound care." I otherwise make it a point to send someone off to a specialist essentially only if they need a procedure. I rarely get a note back from a referral with much more of a work up than was already done. I try to make it to the limits of what we can possibly do before getting someone else involved. I'll wind up practicing in a place almost as subspecialty-barren as you one day, if everything goes my way.
You did right. I do a ton of derm, drain abscesses, inject joints, laceration repairs of course, fracture management (but not as much as I used to) and I'm not scared of complicated pt's with numerous comorbid conditions. I did used to scope, but it was a time vampire due to travel time to and from GI lab. I love precepting residents that are eager to learn. I have no problems training my future competitors. Steel sharpens steel.
Posted on 4/10/16 at 10:13 pm to SaintsTiger
quote:
Are you suggesting that the conceived general emotional intelligence of nurses drives patients to want to see nurses and not physicians, specifically APRNs without physician oversight?
I think many patients/clients perceive the person they have the most interaction with as more knowledgeable and or competent than the behind the scenes professional. Think paralegal/lawyer, nurse/doctor, and bookkeeper/CPA. What I think they fail to realize is that while, yes, the paraprofessional is really good at handling the routine, run of the mill service, the professional's judgment and experience are invaluable.
I personally have a high deductible plan and pay for my routine office visits through an HSA. I'm glad that the clinic I go to for the flu or whatever has mid-level practitioners working there since it keeps costs down and reduces my wait times. I would not go there if a medical doctor wasn't supervising behind the scenes. If something comes up I certainly want the benefit of that person's expertise and judgment.
Posted on 4/10/16 at 10:17 pm to SaintsTiger
quote:
I would say he's misinformed. If you do it well, the sky is the limit. And I mean legally. I've told my NP's the same. But the only way to do it is busting arse and taking care of people. I ran into an old doc that I knew when I was little. He was stopping by to see all the renovations and additions at my clinic and reminded me, "See, if you do what you're trained to do, do it well, and take care of the pt FIRST, everything else falls in place." There is a tendency to get caught up in dollars and cents due to the business like nature of medicine now. But periodically I have to bitch slap myself and remind me to focus on patient care and service first and foremost. Then worry about the money. I'll be damned. When I forget about the money for awhile and check...it's there with lots of friends. Like I said earlier, I can be a real dick on here sometimes, but IRL I take care of my pt's, I go above and beyond, and they love me and I love them...for the most part. I think I'm getting a little drunk and rambling, but When I go, I want to be that old arse country doc that everyone loved and no one can replace. And to train the next in line. Our practice has been here since 1954. I feel an obligation to this community and area to grow in and make sure it's here in 60 more years.
Thank you
Posted on 4/10/16 at 10:51 pm to SaintsTiger
quote:
1. Why doesn't the AMA allow more medical schools to open up in the US? That would increase physician populations and access to care while, under the law of supply and demand, decrease patient costs and decrease medical education costs.
Number of schools isn't a problem, graduate medical training is.
quote:
2. To many, nurses as a group seem more emotionally intelligent than medical doctors. If docs as a group improve their bedside manner, patients will like them more and, for example, be more likely to head their advice. If the patient feels heard, she is more likely to listen...
no argument here
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