4.30.2010

Psychiatrists masquerading as real doctors

(OK, before any of you harangue me about the post title, it is meant totally [mostly] in jest. Of my very best friends from medical school, three went into psychiatry. I briefly flirted with switching to psychiatry during residency. But most [honest] psychiatrists will also tell you that they turn a ghostly shade of pale when confronted with any non-psychiatric medical problem. Anyhow... onward.)

One of the nurse practitioners in the office forwarded an article to me from Fox News. (There is next to no chance I would ever have seen this otherwise, because Fox News makes me break out in itchy, itchy hives.) She was not amused:

Nurses Masquerading as Doctors

The growing shortage of medical doctors, which will be made much worse by health care reform, will mean more and more patients are cared for entirely by “nurse specialists” and nurse practitioners, instead of physicians. Nurses are lobbying for increased prescribing privileges and for the right to be addressed as “doctor” in health care settings.

I'm actually going to go through this bit by bit, because there's just so very much crap to deal with. First of all, the author (one Dr. Ablow) stumbles right out of the gate, because apparently he cannot tell the difference between nurses and nurse practitioners. The latter have much more training, which is why they are allowed to prescribe medication. In addition, so far as I am aware, the "nurses" who are lobbying to be called "doctor" are ones who have a doctorate in nursing. While I have some qualms with that (there is genuinely a difference between medical training and nursing training, even to the level of doctorate), Ablow does not bother to make the distinction.

People who can afford to bypass insurance altogether and simply pay to see doctors will increasingly do so. Why? It’s simple: Doctors go to medical school, which is much more rigorous academically and intellectually than nursing school. They also were admitted to medical school, which is a much more competitive process than being admitted to nursing school. The average doctor has more training, relevant experience and raw intellect than the average nurse–period.

Well, most nurses probably possess sufficient training, experience and raw intellect to know the difference between a nurse and a nurse practioner.

Let's just pause now, and clarify something. Nowhere have I ever seen anyone in any
health care setting cared for by a nurse when a doctor should have been involved. Plenty of people get cared for perfectly appropriately by nurse practioners, but this distinction is completely absent from Ablow's rant. As such, it is totally devoid of merit, because he is describing a phenomenon that does not actually exist, and conflates two different categories of medical provider.

Saying such things plainly isn’t popular, of course. The fact that the health insurance premiums of Americans won’t even get them access to the minds of doctors in many clinics and ERs and even ORs (where nurse anesthetists work behind gowns and masks, just like anesthesiologists) is one of the “dirty, little,” gigantic secrets of how our health care system is giving consumers less for more. No one is supposed to offend anyone with the truth, anymore, after all.

Behind gowns and masks?!?!? Just like doctors? (And also scrub nurses?) Don't they know those are special, "doctors-only" items. Nurses are supposed to wear those cute little hats, white hose, and saucy expressions.

Want to know something that Ablow doesn't mention? Any evidence that nurse anesthetists (who, like nurse practitioners, have training far beyond that of ordinary nurses) have worse outcomes managing anesthesia than anesthesiologists. Wanna know why? Because there isn't any.
Want a little truth right now? No man or woman in his or her right mind would prefer to routinely talk to an on-call nurse when his or her child is sick, rather than a doctor. No one sensible would want a nurse, rather than a doctor, assessing whether to get an MRI or CT scan or neither one after an episode of head trauma. No one would want a nurse, rather than a doctor, to decide whether to get a cardiac stress test in the setting of chest discomfort.

Want a little truth now? Many, many offices use triage nurses to answer routine questions. Like, for example, mine. If, in the middle of the night, the phone nurse needs to consult me, I get called. It's a system that works just fine.

Want a little more truth? No nurse would be making the decision about head scans or stress tests Ablow posits. Maybe a nurse practitioner might.

Want just a teensy bit more truth? Every single nurse practitioner I have ever worked with (and I have worked with them in many settings, managing everything from chemotherapy to contraception to eczema) has had an appropriate appreciation of his or her level of knowledge and expertise. They have consulted me or my colleagues when they felt they needed back-up (just like I do when I want another opinion), and no-one's care has suffered as a result of an inappropriate blurring between doctors and "nurses."

How about some more truth to go with all that truth? Sometimes, for fields where I don't have as much experience or training (psychiatric medication management springs to ming), I have consulted with nurse practitioners!! Because, contra Ablow, they are trained medical professionals who know what they're doing.
How come no one is flying into an American city today to see a famous nurse, while people arrive from countries around the world to visit with noted American physicians? How come no one in Congress would be able to tell you a story about that incredible nurse who diagnosed the rare condition in his or her child? How come nurses either failed to be admitted to medical school or didn’t try? You think it’s because they thought nursing school would train them better to take care of patients? C’mon. It’s because nursing school is easier–as in, 10 times easier.

I'll let you in on a little secret. You know those people who fly from all over to go to the best medical centers with all them famous doctors? I'm willing to bet that many of them received care at one point or another from a nurse practitioner. Because a lot of those famous-doctor-having centers also employ nurse practitioners.

Also, many nurses were admitted to nursing school because they wanted to be nurses, a possibility that seems to have escaped Ablow.
I almost feel sorry to be so blunt. I don’t want to hurt anyone’s feelings. If nurses stop impersonating doctors, I’ll stop writing about them impersonating doctors.

I almost feel sorry to be so blunt, too. Dr. Ablow is an idiot. (I don't care that he went to Brown and Johns Hopkins. I have met plenty of idiots at fancy schools.)
Until then, just follow the money; people with enough of it will hire physicians, every single time, when they have real health concerns. The vast majority of Americans, on the other hand, whose health insurance is rapidly costing more and buying them less, will see health care workers who chose not to go to medical school and probably would have been turned down, anyhow.

Oooooh. Guessing! I love guessing!

Maybe Dr. Ablow went into psychiatry because he couldn't get into a more competitive residency! Maybe that's why he's a self-help-book-writing hack who can't tell the difference between two different kinds of health care providers! Maybe he writes for Fox News because they thought he was too dumb for MSNBC!

Or maybe he's the kind of self-important prat who gives doctors their reputation for unjustified arrogance. Either way, he doesn't know what the hell he's talking about.

10 comments:

  1. Just wanted to add that my son's GI care provider is a nurse practitioner, and I love her. She's super-bright, well-informed (indistinguishable to me from a doctor, and has better instincts, I think, than many of them), and willing to discuss things with me, in person and via email, at greater length than any doctor I've ever dealt with.

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  2. Well, y'know... some doctors are OK.

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  3. My sister in law is a nurse practitioner, and you want to know another little secret, they get paid a lot less than doctors, which helps make health care costs cheaper. My wife is in nursing school and she recently did a clinic at a major Hospital where the only person who saw patients during her shift was a nurse practitioner. My wife knew she was a nurse practitioner, she told my wife she was, and everyone there knew.

    And I would love for my wife to go on to become one herself, but it is a very long haul in itself.

    charo

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  4. Guessing - maybe Dr. Ablow's article, written for Fox News, was partially driven to create resistance to intended health care reform, which passed, what, by one vote? Both Hilary Clinton, way back when, and Barack O'Bama have stated (one way or another) that increasing the use of nurse practitioners in a managed care system will save $ - less cost to educate, less cost to pay, and save on cost by saving physician care for acute care needs. Dr. Ablow seems not to know much about providers of health care (understatement), but he seems to know a little about creating fear.

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  5. Clearly, the US needs to free doctors from doing the routine; we don't have enough physicians as it is. It only makes sense to put the NPs and PAs on the front line of healthcare, and call in the physicians when indicated. This is exactly the kind of medical reform that our society needs.

    Dr. Ablow is a psych correspondent, and he's well out of his expertise here.

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  6. Darn blogspot. The above comment was from the keyboard of Dr. Gadfly John, CEO of Evil, Inc.

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  7. To clarify: I like her as much as the best doctors, but there's more of her. It's like an all-you-can-eat buffet of health care! And, of course, a certain other doctor has trumped everyone by being noticeably fabulous in giving hand-holding and free medical advice. You know who you are.

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  8. Dr. BLOW is an idiot. He might want to contact the 50+ doctors I know who have NO PROBLEM having their nurse practitioner see all their patients. They certainly don't have a problem BILLING AT THE DOCTOR RATE for a NP's services, even though they never see the patient and don't even bother reviewing the chart. Of course, the NP isn't getting that money...the doctor is making out BIG TIME! But, when the NPs start opening their own practices and competing with the docs, then all of a sudden they are incompetent. What a JOKE! Of course, when a NP practices independently (in my state anyway), the insurance companies reimburse them far less than they do doctors, so they ARE saving us health care dollars but ONLY if they're practicing independently and NOT under a physician. When is the general public going to catch on to this SCAM? THE MAJORITY OF DOCTORS ONLY CARE ABOUT THEIR POCKETBOOK PEOPLE!!!

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  9. Thank you so much for your thoughts. Although Dr. Assblow's comments are misguided, and clearly establish him as the tool and loose sphincter he truly is, his comments are echoed throughout organized medicine through the AMA and state medical associations.

    The AMA and state medical associations routinely pay millions of dollars to lobby against improving patients access to safe and affordable care delivered by NP's if those NP's are not in a relationship with a physician--collaborative or otherwise.

    Hopefully, the other 81% of the profession of medicine not associated with AMA will start standing up for patients access to safe and affordable care delivered by NP's.

    As for Dr. Assblow, I hope he stays at Fox--well away from patients who might need some form of care.

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  10. You guys are missing the point here people! There is some real truth in his statements, although construed in a very bad way. There is a HUGE, HUGE, HUGE difference in the medical education!!! Sure, I will admit that NP's can do 80% of what a primary care physician can do, but do you want to be the 20% that they can't handle when they think they can? For example, an NP recently misdiagnosed esophageal cancer by calling it CMV esophagitis (an absurd diagnosis given that the patient was not HIV/Aid). Patient suffered mets to the brain and died...

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