The Covert Rationing Blog

Hey PCPs - Here They Come!

June 17th, 2008 by DrRich

The June 16 issue of AMANews reports that the National Board of Medical Examiners will begin offering a certification examination this fall for graduates of “doctor of nursing practice” programs. Revealingly, the test will be based on Step 3 of the U.S. Medical Licensing Exam.

Doctor-nurses will soon be Board Certified, just like, uh, doctor-doctors.

The AMA leadership sees this development as potentially alarming. Doctor-nurses, they suspect, may soon use their new NBME certification status as “as leverage to seek scope-of-practice expansions that cross into medical practice.”

Mary Mundinger, the leading spokesperson for doctor-nurses and not one to mince words, has chosen not to soothe such suspicions. Says Doctor Mundinger, “While a primary care physician went to medical school and did residency, a nurse practitioner with a DNP has achieved many of the same competencies but through nursing education. They have the same skills in identifying a disease state and treating it, but it’s a different hybrid of care.” In other words doctor-nurses have simply taken a different pathway to the same end. Indeed, once doctor-nurses demonstrate their clinical competence, Mundinger maintains, the legal pathways will open to the expansion of their scope of practice.

But the mighty AMA is having none of that. At press time, the AMA House of Delegates was considering several new resolutions that would challenge this clear encroachment on the turf of American PCPs. For instance, the AMA will consider endorsing a policy that recommends that the title “doctor” be reserved for physicians (and dentists, podiatrists, PhDs, and certain sports figures such as Dr. J. - but not for nurses). Another resolution the AMA may (or may not) consider would recommend that the title “resident” be reserved for those in a medical (or dental or podiatry) training program and, presumably, for denizens of nursing homes - but not for those in the “residency” portion of the doctor-nurse training program. The House of Delegates may even consider resolutions protesting the NBME’s decision to offer a certification exam to doctor-nurses in the first place. (The NBME has already responded to such complaints: “We’re a testing organization, and this fit our mission,” said a NBME vice president who, incidentally, is an MD himself.) Finally, the AMA may resolve to “insist” that doctor-nurses practice medicine only under the supervision of doctor-doctors. The American Academy of Family Physicians has threatened to join the AMA in considering these strong actions.

So, it appears, the professional bodies representing the interests of American PCPs may very well adopt the same Ultimate Weapon often employed by the United Nations when it confronts aggressive, threatening dictators around the world (such as Iranian President Ahmadinejad who, while ignoring calls from the UN to abandon his nuclear weapons program, simultaneously threatens Israel with annihilation). In other words, the AMA and AAFP are very close to pulling the trigger to counter a clear and present, self-declared, existential threat with the dreaded Strongly Worded Letter.

Dr. Muldinger is, no doubt, really, really scared.

This is all, of course, a kabuki dance. If the government, the insurers, the AMA, and their own specialist colleagues really cared about primary care physicians, they would not have systematically devalued their training, expertise and time. They would not have allowed the practice of primary care medicine to be reduced to a series of handed-down “guidelines.” If their own professional organizations cared about them, they would not have adopted a new code of medical ethics that make doctors primarily responsible to society’s needs instead of the needs of their patients, thus removing any true professional distinction doctors might have from “lesser” practitioners like doctor-nurses.

The remarkably anemic response of the AMA and AAFP to the aggressively ascendant doctor-nurses, of course, merely reflects how truly weakened the position of PCPs has become. PCPs are, and have allowed themselves to become, well and truly screwed.

Having taken such careful pains to make primary care medicine so exquisitely unattractive to present and future physicians as to assure that the growing “PCP shortage” will become the next real medical crisis, the healthcare system is now grooming its solution to this manufactured crisis, namely, the doctor-nurses. These doctor-nurses will fulfill all the criteria the healthcare system desires for its practitioners of primary care medicine (no matter what healthcare reforms we may end up with). They will be “doctors” who are duly “certified” in primary care medicine by respected testing organizations, who have just enough training to diagnose and treat the average patient (i.e., the ones with high blood, low blood, fat blood and sugar), and who will cheerfully, unquestioningly (and with far better compliance than MDs - what with their traditions, attitudes, etc. - can ever hope to offer), follow whatever guidelines are handed down to them by the experts. And they will do it all for less pay and with less lip than the now-obsolete physician PCPs. These new practitioners of primary care medicine will be a perfect fit.

DrRich sees no future in PCPs wasting what little emotional and professional capital they may have left in fighting an ultimately doomed rear-guard action against the doctor-nurses. Given the present state of our healthcare system, the rise of doctor-nurses is as inevitable as the rise of the middle class at the end of the feudal era. There’s little to be gained here in fighting history.

Instead, PCPs need to recognize the realities, and completely reinvent themselves. DrRich has previously suggested how they might approach this difficult but enlivening task. Now that the doctor-nurses have taken another major step to becoming the primary care deliverers of the future (an eventuality which the healthcare system has done everything to arrange), perhaps more PCPs will begin to think more usefully about how they can reinstate their professionalism, and remake themselves in a more sustainable form.

But whatever they do, hitching their hopes to the verbal ejaculations of the AMA, the AAFP, or any other of the professional organizations that have led them to this impasse, seems a particularly useless strategy, every bit as useless as sending the blue-helmeted peacekeepers off to fight your battles for you.

Posted in Primary Care in America

14 Responses to “Hey PCPs - Here They Come!”

1. BladeDoc wrote on 06/17/08 at 7:04 pm :

   Dr. Rich — do you read NHS Blog Doctor? It seems that the Brits are already way down this path (see his posts on “dumbing down”).

   I’m in no way affiliated with the site BTW.

2. DrRich wrote on 06/17/08 at 8:56 pm :

   BladeDoc,

   Yes, it’s a great, classic blog. I need to put it back on my blogroll. (I took it off when he went on hiatus several months ago.)

3. Dan wrote on 06/18/08 at 9:21 am :

   Sadly, with the advent of the “medical home”, I believe PCPs are going to be digging their own graves, and paying for the shovels to boot!

4. A Skeptic wrote on 06/18/08 at 12:51 pm :

   DNP residency training programs cannot exist without substantial physician participation. If physicians refuse to be preceptors, faculty, etc. for these programs, this movement will not take off. The nursing profession cannot do this on its own. Will the AMA and AAFP go so far as to officially recommend to their membership not to participate?

5. DrRich wrote on 06/18/08 at 12:59 pm :

   Skeptic,

   Aside from the fact that doctor-nurses so neatly fit what the healthcare system craves for the primary care niche that they are as inevitable as hurricanes, physicians’ groups like the AMA and AAFP are too weak (not to mention politically correct) to try anything as direct as what you suggest.

6. Dr John Crippen wrote on 06/19/08 at 8:05 am :

   Oh boy!

   Dr Nurse?

   No, we have not got that far, as yet. But of course, what happens in the USA tends to float across the pond and appear here a few years later. It’s happened with out dentists who, like yours for many years, have now taken to calling themselves Dr. Crazy, really, because in the UK real surgeons, as you know, have always called themselves MR (in homage to their barber origins) to distinguish themselves from physicians. And yet dentists would purport to be surgeons and so, in the UK, by calling themselves Dr they are denying there surgical skills.

   It’s all semantics really. The man in the street things that a doctor is someone who has been to medical school and so will assume that Dr Nurse has been to medical school.

   We already have Consultant Nurses.

   Nurses in the UK are now far more important than doctors. I think I am going to start calling myself Nurse. Or maybe I should just increase my medication!

   John

7. Edwin Leap, M.D. wrote on 06/19/08 at 8:50 am :

   In South Carolina, where I practice emergency medicine, nurse practitioners and PA’s practice essentially the same medicine. But NP’s pay about $500/year in malpractice, vastly less than physicians or PA’s.

   What does this have to do with Doctor Nurses? A lot. I believe that most nurse practitioners, and ‘doctor nurses,’ enjoy what they do because they aren’t usually the final level of responsibility. Often, a physician is posted somewhere up the chain of command, and he or she pays the malpractice and takes the heat for errors.

   The Doctor Nurses, with all their alleged compassion and brilliance, may begin to take a larger role in medical practice. But when people start dying, and caring, holistic, compassionate Doctor Nurses are accused in court of being inadequately trained; when the jury hears them say ‘no I’m not a physician, I’m a doctor nurse!’ and awards $10 million in damages; when their malpractice insurance rises exponentially; when, in response, they have to start billing like doctors to cover overhead and billing costs and malpractice and fees; when all nights, weekends and holidays have to be covered in their clinics and it suddenly stops being an exciting exercise in prestige and lab coat wearing and being called ‘doctor,’ then we may see them scurrying back to the relative safety of ‘Nursedom.’

   I could be wrong. But I have a sneaking suspicion that I’m right.

   Edwin Leap, MD

8. DrRich wrote on 06/19/08 at 8:59 am :

   John,

   Sounds like what you need is for the AMA to come over and sort out the nomenclature for you.

   Rich

9. DrRich wrote on 06/19/08 at 10:03 am :

   Dr Leap,

   I tend to agree that the final joke may very well be on the doctor-nurses and the system that raised them up. Delivering primary care medicine under this system is a loser for whomever ends up doing it.

   If, in the meantime, physicians can reinvent themselves in a way that reestablishes their professionalism, they’ll be ready to receive the supplicants (when they come back to them for help, hat in hand), on their own terms.

   Rich

10. Annie wrote on 06/24/08 at 1:29 pm :

    What nurse bashing this is and based on what? Fear of competition? As a doctorally educated nurse myself (not a DNP)and not associated with Mary Mundinger or the DNP curricula, I’d like to inform you that doctoral education (pdf) in nursing isn’t a newfangled entity. It’s been around for most of the twentieth century, and the minority of nurses educated at the doctoral level use the title, doctor as an academic one. We do not use the title as a medical doctor.

    Nurses across all practice and clinical settings have ALWAYS identified themselves as nurses to patients and to other providers as the standard, regardless of the academic degree held.

    There are so few nurses educated at the doctoral level that the nursing shortage will only grow due to the increasing dearth of educators, researchers and advanced practice clinicians.

    And if you look at access to primary care numbers (look in MA since it most recently mandated health insurance coverage - The Commonwealth Fund has the most recent study) and note that with increased numbers of covered lives, the access becomes very problematic very quickly. There is more than enough patient need to go around. No primary care physician practice is going to be financially threatened by having more nurse practitioners.

    Finally, let’s take a look at patient quality and satisfaction measures with nurse practitioners and primary care physicians.

    Instead of creating yet another battlefield of interprofessional competition, why not collaborate on making primary care providers - physicians and nurses - a power base from which to mutually improve practice, reimbursement share and patient outcomes?

    One trend that physicians are learning isn’t necessarily in their best interest is that of practicing as employees of patient care organizations. Nurses have practiced within this framework traditionally, and managers were split from clinical nurses, to the detriment of both and to patient advocacy, which suffers. By bringing nurses together in self governed professional practice groups and contracting professional nursing directly to patient care organizations, there would be an opportunity for nurses to select their own leaders and to consolidate professional power and autonomy.

    There is also a great opportunity for physician professional practice groups to add nurses and contract both services. That collaboration could make a powerful impact on the modes of care delivery, the scope of services provided and the autonomy of both professions.

    Finally, Dr. C Fay Raines of the American Association of Colleges of Nursing wrote a response to the AMA resolutions. The AACN also wrote a DNP white paper, and it is the body that is the authority on the DNP (not Dr. Mundinger as you attest).

    On behalf of the American Association of Colleges of Nursing (AACN), which represents the nation’s nursing schools with baccalaureate and graduate programs, I am writing to address concerns regarding Resolutions 303 and 214, which are coming forward to the American Medical Association (AMA) House of Delegates for a vote later this month. AACN is distressed by the tone of these resolutions, which may weaken the good working relationships established between many physicians and nurses. Both resolutions serve to stall the national movement underway to prepare a strong cadre of doctorally prepared nurses and to enhance the transition and retention of new nurses in the workforce, which is essential in improving access to and quality of healthcare. AACN requests that the AMA withdraw Resolutions 303 and 214, and if that is not possible, we urge members of the AMA’s House of Delegates to vote against these measures.

11. L-E wrote on 06/30/08 at 10:28 am :

    Additional information related to this was quoted on hcrenewal.blogspot.com recently:

    American Health Lawyers Association (AHLA) alert

    CMS Modifies “Incident To” Restrictions at Provider-Based Sites

    By Kelly R. Anderson*

    On June 19, 2008, the Centers for Medicare and Medicaid Services (CMS) posted the July 2008 Update of the Hospital Outpatient Prospective Payment System (OPPS).

    Notably, in the update, CMS announced revisions to the Medicare Benefit Policy Manual “to remove language stating that services furnished in provider-based departments of hospitals must be rendered under the direct supervision of a physician ‘who is treating the patient.’” This is a much-anticipated modification for hospitals and their lawyers since the release of Medicare Transmittal 82, in February 2007. Transmittal 82 required provider-based clinics to furnish therapeutic services under the direct supervision of a physician who is treating the patient.

    According to CMS, the language of Transmittal 82 has caused confusion in relation to the requirements of the Code of Federal Regulations. Prior to the release of Transmittal 82, the Code of Regulations provided that services furnished incident-to in a provider based hospital outpatient department required the oversight of a supervising physician who is immediately available in the event of an emergency, but not necessarily the treating physician. 42 C.F.R. § 410.27(f). It appears that for services furnished incident-to in a provider based hospital outpatient department, hospitals may again rely on the supervision of a physician who generally does not have a treatment relationship with the patient.

    View the July update (Transmittal 1536).

    *We would like to thank Kelly R. Anderson, Esquire (Baptist Healthcare System, Central Baptist Hospital, Lexington, KY), for providing this email alert.

12. DrRich wrote on 06/30/08 at 1:47 pm :

    Annie (and L-E),

    I’m sorry, Annie, that I made you think I am bashing nurses. I am not. I like and admire nurses, and actually believe that most of the nurses I know have maintained their fundamental ethical and moral principles better than many doctors I know - and certainly better than the professional medical organizations which formally pronounce on such things.

    My comments were mainly aimed at satirizing the response of the emasculated and morally bankrupt medical establishment to the encroachment by nurses on what has traditionally been medical turf. If you had read my previous writings you’d understand that such encroachment is not evil or bad, but simply the normal pattern wherever advancing technology enables lesser-trained individuals to do things that in the past required highly-trained specialists. I would never bash nurses for simply playing their natural part in the evolution of a technological society.

    I do find somewhat amusing, however, the quotation you provide from the AACN protesting that the AMA is accusing them of doing what, in fact, they are doing. I’m sure it’s not your intent, and it’s clearly not the policy of the AACN, either, to replace PCPs. But it’s happening just the same, as the night follows the day. Neither the PCPs, nor the nurses who may be startled and intimidated by the prospect, can ultimately stop it.

    Those who do view the encroachment by nurses as an evil deed will see the protestations of innocent intent by AACN - while actions on the ground so clearly contradict them - as something similar to the soothing murmurings of the Japanese Ambassador while preparations for Pearl Harbor were in their final stages. I see it, on the other hand, as an indication that most nurses are as apprehensive as are the PCPs they are displacing - what with all the responsibilities this will entail, medical, moral, legal, and otherwise. Historical upheavals are often unkind to all parties involved.

    If further evidence is needed that I am correct (beyond simply studying the history of technological societies), simply read the comment preceding this one from L-E. CMS is already there, and is very obviously clearing the path for the inevitable. Everybody needs to get ready for this - the nurses, the PCPs, and the patients.

    Rich

13. Family Doc wrote on 07/6/08 at 1:55 pm :

    How about this: Doctor Nurses will be accredited when they complete 2 years of pre-clinical classes of the same rigor as medical school classes (we all know that the nursing classes are *not* to the same level as med school classes), pass Step 1, take 2 years of clinical rotations, pass Step 2 CK and CS (and pay for both), and then complete 3 more years of clinical supervised work and pass Step 3. Then I will be happy to consider them my equal in providing primary care. Until then, sorry.

14. Christian Larsen wrote on 07/9/08 at 10:37 pm :

    Actually the proposed regulation did not pass. It is interesting that these regulations would have prevented Ph.D. level clinical psychologists to refer to themselves as “Dr” when working in medical settings. This was regarded by our profession as an outrageous assault on our professional standing. As holders of an academic degree higher than an MD degree, with extensive training as scientist/scholar practitioners, with as many years of graduate level training as physicians, with extensive research expertise most other health care professions lack, these proposed AMA regulations could have deeply damaged the relationship between the professions of clinical psychology and medicine. I would suggest that the AMA push for the term “physician” to be a protected title in the same way that the term “psychologist” is legally protected in most states. In addition, ethics codes and regulations should explicitly make it a violation for a doctoral level professional to misrepresent their professional affiliation.

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