Family physician, author, blogger, speaker, physician leader.

Why Nurse Practitioners Should Not Do Primary Care Without Physician Oversight

“She said my back pain was caused by micro kidney stones.”

So said my newest patient after her previous primary care provider, a nurse practitioner retired.

“Micro kidney stones?”

I didn’t know what else to say. Having practiced as a board certified primary care doctor for a decade, I’d never even heard this term.

Nurses Are Not Doctors

So the NY Times opinion piece that “Nurses Are Not Doctors“, penned by Dr. Sandeep Jauhar, author of Doctored: The Disillusionment of an American Physician, resonated with me. The fact that 17 states have legislated nurse practitioners the right to practice primary care medicine without physician oversight is very worrisome. There is a primary care crisis. We do need more primary care providers. Though nurse practitioners can fulfill some of the demand they cannot do so without doctor oversight. Though on paper it seems like what primary care doctors do is easy, in fact when digging a little deeper, one finds out these two specialties are not the same though some states view them as such.

It boils down to training. Primary care is a cognitively challenging specialty. The amount of training doctors receive is far greater than that of nurse practitioners.

As Malcolm Gladwell, best-selling author of Outliers: The Story of Success noted in a 2013 New Yorker piece regarding the 10,000 hours of deliberate practice  observation -

  • Forty years ago, in a paper in American Scientist, Herbert Simon and William Chase drew one of the most famous conclusions in the study of expertise:
    There are no instant experts in chess—certainly no instant masters or grandmasters. There appears not to be on record any case (including Bobby Fischer) where a person reached grandmaster level with less than about a decade’s intense preoccupation with the game. We would estimate, very roughly, that a master has spent perhaps 10,000 to 50,000 hours staring at chess positions…

AND

  • But the ten-thousand-hour research reminds us that “the closer psychologists look at the careers of the gifted, the smaller the role innate talent seems to play and the bigger the role preparation seems to play.” In cognitively demanding fields, there are no naturals. Nobody walks into an operating room, straight out of a surgical rotation, and does world-class neurosurgery.

 

The issue is also making the right judgement calls. Primary care is where most patients present for the first time to the health care system. With their constellation of symptoms, it is the listening, examining, and diagnostic skills of the primary care provider that makes the difference between ordering the right tests, the right treatments, and if needed, the right referrals or ordering too many unnecessary tests, prescribing inappropriate treatments, or generating extra referrals.

So how many hours of training do nurse practitioners receive? Per the oped piece.

AND

  • Medical school graduates, after two years of classroom instruction and two years of clinical training, are not considered fit to practice medicine independently. Yet in New York State next year, nurse practitioners with perhaps even less clinical education will be allowed to do so.

 

Primary Care Is Not Simple Or Easy – Doctor Training Is Different

If primary care was so simple and easy, perhaps these concerns of inadequate training would be overblown. Who doesn’t know the symptoms of a bladder infection? Heartburn? Seasonal allergies? Either doctors or nurse practitioners can play the role well.

What differentiates doctors from nurse practitioners is our training, clinical experience, disciplined thought process, and a framework to problem solve provide a depth of understanding that simply is lacking in nurse practitioner training. Patients don’t present with the classic textbook description of an illness. Though medical school professors reminded us that when evaluating symptoms and to diagnose the more common and obvious ailment — “when you hear hoofbeats, think horses not zebras”,  the world has gotten more complex.  Outbreaks of once eradicated childhood illnesses spread by international travel to our shores. Patients are living longer with chronic illnesses and on multiple medication regimens. Can nurse practitioners make the correct judgement calls on increasingly complex patients in primary care?

Understanding what you know is as important as admitting what you don’t know. Micro kidney stones?

What Do Patients Want? What is the Job to be Solved?

Finally, one other perspective one might consider is “what is the job that the customer has hired me to do?

As Professor Clayton Christensen of Harvard Business School noted in the Milkshake Marketing piece, we need to think about solving people’s problems in this way:

  • “the jobs-to-be-done point of view causes you to crawl into the skin of your customer and go with her as she goes about her day, always asking the question as she does something: Why did she do it that way?”

AND

  • “Several major companies that have succeeded with a jobs-to-be-done mechanism: FedEx, for example, fulfills the job of getting a package from here to there as fast as possible. Disney does the job of providing warm, safe, fantasy vacations for families. OnStar provides peace of mind… Nobody, for example, has managed to copy IKEA, which helps its customers do the job of furnishing an apartment right now.”

When she has symptoms, she is trying to find a solution to allow her to feel better or to remove any worry or anxiety generated by the new symptom. This is when she seeks care with a primary care provider. Sometimes understanding the cause of these symptoms is clear. The treatment straightforward.  Other times, the diagnosis may not be clear. The work-up requiring more thought.

Both the patient and the provider cannot know prior to the encounter whether the resulting diagnosis, work-up, and treatment is simple or complex. When a patient has a new problem, the job she is trying to solve is for someone to help her. Whether the solution is simple or complex will depend on the provider’s ability to determine it as well as the patient’s illness.

Policy Makers Are Mistaken. Nurse Practitioners Are Not As Capable as Primary Care Doctors

Yet, policy makers believe that nurse practitioners are as capable as primary care doctors in discerning these clinical differences. Policy makers believe nurse practitioners can practice independently from doctors and be free of oversight in the cognitively demanding specialties of internal medicine and family medicine.

I don’t. The observation of deliberate practice of 10,000 hours and the reality that primary care sees both simple and complex problems in an unpredictable manner coupled with the double standard of different training and different certification training suggests that nurse practitioners are not ideally suited to be front-line providers free of physician oversight. Should nurse practitioners want this independence, they should be held to the same certification standards as doctors.

Nevertheless, if policy makers feel primary care is a job that nurse practitioners free of physician oversight can solve for patients seeking initial care, then they might wish to allow nurse practitioners to expand into another specialty:

Emergency medicine.

90 thoughts on “Why Nurse Practitioners Should Not Do Primary Care Without Physician Oversight”

  1. I have encountered a nurse practitioner working with my surgeon. I have no idea where she begins her involvement and where my surgeons’ begins. This should not have to happen. I did not know if she was supposed to make the decision or not. Personally I did not want to work with her. She was overly emphatic, which made me suspicious of her motives.
    I don’t think my surgeon appreciated her looking over his shoulder and listening to his prognosis.
    Get them out of my way.

  2. It is not uncommon for all levels of healthcare providers to use simplified, lamen’s terms names for conditions to help patients understand their diagnoses. Kidney stones range in size, and perhaps the patient did have very small kidney stones. Your opinion piece does not offer enough information to make an educated, unbiased decision regarding the quality of care provided to the patient you are discussing. Nurse practitioners receive 4 years of undergraduate healthcare training, often work full-time for several years before applying to nurse practitioner school (often preventing patient harm by physician mistakes & making suggestions regarding the best care for patients to their physicians), and then receive their master’s degrees as nurse practitioners. Additionally, there is a call for nurse practitioners to achieve their DNP prior to practicing independently. No, nurse practitioners are not doctors, they are advanced practice clinicians whose experience and treatment is different from that of physicians, but no less safe. Numerous studies have revealed that nurse practitioners provide care that is equal in quality to that of physicians, and that patients often report that NPs have better bedside manners and do a better job educating their patients how to take care of themselves. Your opinion here is clearly biased, and offers no research-based information to support your claims that nurse practitioners provide inferior care. NPs are just as invested in protecting their licenses as medical doctors are, and are equally capable of providing quality care to their clients.

    • You are correct, it is possible that this nurse practitioner was using layman terms. What I didn’t clarify in this piece was his back pain symptoms which lasted at most a second or two, were not constant, and would come on a couple times and then be gone for weeks to months on end. No imaging studies, urine testing that showed any evidence of any kidney stone, let alone “micro kidney stones”.
      Agree that the training of nurse practitioners is indeed different from that of physicians, but saying it is no less safe is an assumption. You can’t know what you don’t know. You can’t see or can’t hear what you have not been trained to find. As the NYT piece illustrated the amount of training hours differs. A comparable analogy would be airline pilots. Today many are trained in flight school. Years ago many were trained in the military. Are they about the same? In basic routine situations, yes. But in more complex and difficult situations – no. Nurse practitioners do have a role in primary care. They should not do so, however, independently and without physician oversight.

      • Doctor is a title, not a profession. All NP’s will be doctors from 2015 on.

        Med school is a fraternity. Unless you’re becoming a surgeon, you have wasted your time. They haven’t changed the curriculum in 60 years, and the evidence shows the NP’s deliver the same, or better, level of care.

        Nothing you posted demonstrates any lack of insight or acumen on the part of the NP.

        • The evidence that NP are better isn’t quite as simple as many believe. As noted here
          “Dr. Jane Fitch, president of the American Society of Anesthesiologists, began as a nurse anesthetist but later earned a medical degree. Speaking out against nurses practicing independently, she looks back on being a nurse and says, “I didn’t know what I didn’t know.”

          Nursing organizations suffer from that over-confidence.”

          http://nypost.com/2015/01/06/when-a-nurse-is-your-health-care-provider-youre-at-risk/

          • Do your homework before you make statements regarding care being suboptimal from NPs. On the contrary, research has shown that care is equal or better when it is provided by an NP.
            Journal for Nurse Practitioners. 2013;9(8):492-500.e13.
            JAMA. 2000;283(1):59-68. doi:10.1001/jama.283.1.59

            As an FNP with a private primary care practice in NY, I can attest that I have been consulted by MDs for my knowledge and contributing to a patient’s care and diagnosis. I also do not hesitate to consult with my MD colleagues, if needed. I can also say that most of my patients prefer the NP as we spend more time talking with the patient and not at them, understanding them as a whole person and not just a diagnosis or condition. They prefer the wholistic approach, vs the diagnose and treat approach. One is not better than the other, just different.

        • Would you mind telling me when you wrote this article? I am doing a paper for school and this article was perfect for my research.

          Becky

        • What are you smoking. Np are great you can never have too much education but they are not doctors. Just a way that hospital systems can make more money for less. And if they mis a diagnosis oh well. We are fucked political correctness is destroying us.

          • My NP order almost every test medicare allowed then Dump3d me. Thats right had her office call to say Why are you coming? She had set up the appointment , she said to go over all the tests. Had 5he nerve to tell me well you got your physical for the year. Didnt bother to ask if i still had my problem , which i still do. When i asked if she conferred with an M D her office said she didnt have to. If N P dont need q md degree then why do Doctors. She ended asking when did i want to make a well visit , 6 months or a year. I wanted to tell her When Hell Freezes Over!

        • Clearly, to make such an ignorant statement, you are either 1) just ignorant, or 2) could not get into medical school.

          Nurses will never replace doctors, nor should they.

          • Perhaps many Advanced Practice Registered Nurses (APRNs) would have gone to medical school, if they so desired. Being a nurse is what most APRNs love about their role and is the defining element. What most do not understand, is that there is a stark difference in a disease focused (medical) and a holistic (nursing) approach. Nurses appreciate caring for the entire patient, not just a disease and often learn more about preventative care than most physicians do. It has also been demonstrated APRNs spend more time talking with and educating patients than physician colleagues. APRNs do not want to replace physicians. They want to care for patients using evidence based knowledge yet utilizing a nursing approach to their fullest abilities. For those who still believe a medical doctor is at the top of the hierarchy, as we head toward the future of healthcare, these are the people who will be very disillusioned. The healthcare team with varying types of providers is becoming more prominent, the “perceived” physician hierarchy is crumbling and will become archaic. Many are able to recognize physician resistance to this change for what it is. Physicians will always have an important role, particularly in specialty medicine. However, their role is redefining itself and will inevitably change with modern times, which will benefit not only the medical community but the public as well.

        • What is a nurse Practitioner?

          Per the American Association of Nurse Practitioners 2016, NPs are quickly becoming the health partner of choice for millions of Americans. As clinicians that blend clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and health management, NPs bring a comprehensive perspective to health care. Read on and learn why Americans make over 916 million visits to NPs every year.

          How to become a NP

          In short, a nurse practitioner applicant is a registered nurse with a BSN undergraduate degree that has successfully passed a state licensing exam with at least two years experience who has made the decision to return back to school.

          Under Grad Clinical Hours 1200 hours

          NP’s go through a process of extensive training beyond the initial medical training as Registered Nurses.

          By the time I complete my education as a Family Nurse Practitioner, I will have over twenty two years of health care experience.

          As a critical care nurse with over twenty two years of experience caring for patients, I have witnessed many health care providers who lack the judgement and knowledge to accurately diagnose and treat patients.

          Nurse practitioners do not have a monopoly on poor patient outcomes. Physicians are granted a margin of error in which they are allotted a certain number of poor patient outcomes that can lead to injury or death and in many cases are allowed to continue to practice.

          Nurses do not have the luxury of margin of errors extended to other members of the medical profession.

          When a nurse makes an error that leads to the harm of a patient they are barred from working until they undergo extensive training and show proof of academic and moral rehabilitation.

          • And what does that do for the person that was harmed because they didn’t know what they were doing.

            OH, don’t know what you’re doing…well you must need rehilibation and more education then!

      • The future of healthcare is changing the delivery of care and who that care will be provided by. I am a NP and have had the honor of working with excellent doctors that have collaborated with me through the years, we have gained each others respect, it is a relationship. Sad we have no control over our practice or our patients. Office visits are 15 min., we have EMR, QA measures, meaningful use, patient survey scores, not to mention the plethora of medical knowledge, medications, procedures etc that floods our ever changing medical treatment plans to stay current, safe and appropriate 100% of the time. Trust me I can see that doctors have no control over their position in all this. Just do your job whatever that may be , whatever the law allows, personally I don’t think it is all that easy.

      • This is just you speculating. Did you have access to the work up done by APRN? Only so one could dissect her/his care delivery and make appropriate criticism.

  3. I have worked in the large hospital for 25 years (med/surg, ER, Medical ICU & Cadiothoracic ICU) and if you think that doctors are always right, you are sadly mistaken. Some of the things I have seen doctors do are far worse than anything you mention. This one example does not prove anything at all regarding nurse practitioners. I think they must have given you classes in how to be arrogant as well.

  4. It is true that someone outside of nursing may earn their RN & APRN at the same time through minimal training, but far more APRNs fall under my type of training. I earned my BSN RN from approximately 800 hours of lecture and clinicals. I think worked for five years full-time in medical-surgical, oncology, and home health nursing for approximately an additional 7,500 hours of direct patietn care. In graduate school I will receive another 700 hours of direct patient care, not counting the coursework. When comparing my hours to a physician, who enters medical school with no prior health care required, we are fairly close in hours and experience by the time he/she finishes minimal residency requirements. The primary difference is in my holistic model versus a medical model.

  5. As a patient I have to agree with Susan. In my personal experience I have had negative experiences with MDs and POSITIVE experiences with NPs. I choose to see a NP for my PCP and I can tell you why. When I was 13 years old I had severe back pain and at the time was quite literally crooked. When I went to see my pediatrician for the back pain that was progressively getting worse he told me it was “growing pains.” I must tell you that I was visually in the shape of a S. He then proceeded to give me all the vicodin in the world. After 3 months of excruciating pain my parents decided to take me to see a different DOCTOR…. well okay I mean a NURSE doctor, oops wait, no a nurse practitioner. She looked at me for zero point 5 seconds and said “you have scoliosis” proceeded to order x-rays, physical therapy, and an orthopedic consult. Because of HER my NP I am doing much better, I am no longer in the shape of a S because she actually helped me instead of shoving pain pills in my face. I still see her, I love her and I have NEVER had bad care. When I am sick I get seen in a matter of a week. I also see a NP for my vagina. So I, along with most of North America, disagree with you. My kind regards to your Doctor EGO.

  6. I do not and never will feel that any one who is a nurse practitioner is as qualified to make a medical decision as an MD. The amount of education and experience of an MD can never be replaced by a nurse practitioner or a Physician’s Assistant.
    I am not denying the education it took them to get to that point, obviously a lot of hard work. That said it is just not the same and never will be.
    If you go to a group of Doctors, without requesting anyone specific, you get an nurse practitioner or if you are lucky a PA. Where are all the doctors and is it just a matter of who is cheaper to keep on the payroll?
    NOTHING REPLACES MEDICAL SCHOOL. PERIOD.

  7. I was web-surfing for message board material (on the topic of public perception of nurse practitioners) when I ran across your blog. It’s very reasonable; any points I might argue are of a minute, “exception to the rule” variety. Certainly, we will agree that even the best education can’t provide *absolute* quality control, much less clairvoyance. We will also agree that anecdote has limited value. In response to the one you offer regarding micro kidney stones, I offer the time that a medical doctor cited “stress” as an explanation for my bizarre symptoms…when it was actually Lyme disease. These anecdotes are illustrations of individual frailty and failure.

    I think humility is an essential requirement for a scientific mind. Dr. Jane Fitch mentions that she “didn’t know what she didn’t know.” I can’t help but wonder if she thinks she achieved enlightenment via medical school. I think her not knowing what she didn’t know says more about her as an individual than it does about NP education. I’ve not been to medical school, but I did all of my assigned readings in Harrison’s Internal Medicine text. I read it word by word, and I’m not sure what I may have retained. For intelligent folks, simply studying physiology (or anything medically relevant, come to think of it) should provide an ample dose of humility. The amount of information is unwieldy, and despite the quantity of information, humanity is not living in an age of enlightenment.

    I often hear persons of average education express distaste for the arrogance of physicians. One of my friends thinks it’s because they’re from upper middle class backgrounds and thus are unable to relate to persons from lower classes. For whatever reason, a lot of people seem to perceive physicians as having some quality of “other-ness” that hurts communication.

    The NP reactions are here are knee-jerks, driven by ego. Dr. Jane Fitch was apparently in possession of oversized ego prior to medical school. Personally, I do not require the gauntlet of medical school to know where I stand intellectually. I am not an egomaniac. I am imperfect. I am good at using references. I see some connections, I miss others. When someone is on a dozen drugs and has 20 items in their medical history, I tend to believe that seeing every connection/interaction is beyond the reach of mortal humans.

    Why might NPs have egos out of proportion to their abilities? I’ll say that my NP education has contained a good deal of political indoctrination. We’ve also had studies documenting the quality of NP care shoved down our throats repeatedly. I can deliver citations, but I’ve got to get back to my homework. If you want them, just email me.

    Personally, I like the collaborative practice model. I respect the training of the MD/DO that I lack (provided that the USE this training). Attempting to practice independently as a new NP graduate sounds utterly ludicrous. I don’t think I have less self respect than the other somewhat butt-hurt nurses who have commented here, I just have a more reasonable perspective. The ego battles help no one. We should all be focused on trying to figure out what’s wrong with sick people, and trying to figure out what to do about it.

  8. When I first started practicing as a Physician it was intimidating but after rounding with my senior peers I came to understand that most ailments about 80% were of a very common variety and many diagnosed without extensive medical knowledge. I found that my medical expertise were more suited to a tertiary center where people with advanced medical or severe illnesses generally came after a referral from their primary physician.

    I am sure anyone with 10 to 15 years of exposure in a clinical field can pick up on most generally common ailments that effect 90% of the population and I’m happy the mantle is taken up by NP’s. But the whole idea of equal pay for equal work loses its relevance when most states are pushing for NP’s to practice on their own on the basis to reduce medical costs.

    Medical malpractice insurance companies will benefit more since more NP’s will be entering on their own assuming higher risk. Since the ratio of NP’s to Physicians will be higher more malpractice cases will inevitably fall on NPs.

    I see the future of Physicians in primary care will change towards most working in major centers with no real need to work in outpatient clinics. There may not even be a need for family physicians and most will probably become internists or branch out to other specialties.

    Physicians will once again revert back to the older model of talking and taking time with their patients cause they won’t be rushed. NP’s I expect in the future will bear the brunt of the load and will inevitably face the same short comings as physicians, giving little time to patients as their case load increases.

    NP’s here being argumentative by comparing their capabilities to a physician is moot as far as qualification is concerned. In a qualitative based society a physicians MD qualification will always be considered higher than an NP or PA. In the hierarchy of the medical field a Physician is at the top. The scope of practice for a nurse practitioner in the United States is defined by regulatory boards of nursing, as opposed to boards of medicine that regulate medical doctors.

    Someone above (Jay I believe) stated that the curriculum hasn’t changed in 60 years (exaggerated) kind of irrelevant seeing how that all treatments and practices are defined by medical boards that defines a gold standard treatment and that most refer to “up to date” for their latest info also to avoid malpractice.

    If an NP wants to get the same pay-scale, same respect as a physician then there are no shortcuts but to get an MD degree.

  9. I can understand that physicians are upset by “nurses” becoming more synonymous within the primary care setting. What is factual; however, is that many doctorally prepared nurse practitioners are proving their egalitarianism by passing the same final USMLE step in the board exam. So yes, please call me your primary care provider; call me your primary care doctor; call me Jack; I am all of these. With this in mind, what you won’t ever hear of is a nurse practitioner working solo in endocrinology, neurology, rheumatology, or who is a surgeon. If this is something you aspire for, then medical school is the only track to take.
    It’s true you can’t expect a new graduate medical doctor to walk into an OR and perform world class surgery, but you can put a nurse practitioner in an exam room and have them diagnosis and treat strep throat safely. I liken this to any kid can learn to ride a bike in a day; this for the most part is primary care. With a few years of experience though, this once novice strep throat treating nurse practitioner, will have the exact same capabilities of any family physician to think in a “supreme” analytical fashion, use the same “frameworks”, empirical knowledge, and practice experience to effectively care for a more complex and chronically ill patient population. Furthermore, I would not expect a new family medicine doctor to have the wherewithal to do much more than your average nurse practitioner fresh into practice. You have to remember that masters and doctorally prepared nurse practitioners were 90% of the time nurses with “real life” clinical experience prior to practicing in an advanced role.
    Ultimately it all boils down to the individual provider and their commitment to continuing education and professionalism, in which case we shouldn’t conceptualize an entire professions capability to practice independently based on the one nurse practitioner who told her patient that their back pain was due to “micro” stones. Furthermore, family medicine docs and internists need to set their egos aside and stop falsifying the aptitude of other interdisciplinary providers. It is certainly not our fault they didn’t pass the USMLE step 1 with flying colors thereby highlighting their own aptitudes and ability to become one of the aforementioned specialists.
    Advanced practice nurses have a hard road ahead; primarily because of the precedence set for our profession at inception. It blows my mind that Nightingales fundamental theoretical constructs are still being glorified within nursing institutions, as the discipline has undeniably grown markedly away from its premise. As stated by Florence Nightingale, “above all, let the nurse remember to do what she is told, and no more; the sooner she learns this lesson, the easier her work will be for her, and the less likely she will be to fall under severe criticism” (Selanders, & Crane, 2012). With this in mind, the nursing profession today is unrecognizable in quotes like this and should heed caution in over ennobling our founding mother’s rudimentary and feminist views. Moreover, as a nurse working in the 21st century, I remind myself that what makes my discipline unique is not theory alone, but caring for my patients through a multi-disciplinary approach meanwhile paying careful attention to evidenced based medicine in my practice. This is what sets us apart from physicians.
    Lastly, my name is Kathryn and not Jack. It’s unfortunate that most doctors are immediately construed as male and any title with nurse, recognized as female subordinate position.

  10. NPs, but every account, are FRAUDS. They are people who want to “play doctor” without wanting to do the work to be one. If you want to treat patients and prescribe medications, do the work and go to medical school. Don’t be this ambiguous “provider” who does everything imaginable to avoid doing what’s necessary to treat patients. If you don’t have the talent to go to medical school, all I can say, is life is tough. I don’t have the talent to go to medical school, nor do I have the ability to work for NASA. That’s why I’m earning my doctorate in a field in something in which I have an understanding and natural ability. I for one, will not allow an NP to TOUCH me. NPs put people’s lives at risk. They are taking advantage of a healthcare system that wants the McDonalds approach: Cheap and quick. I will fight until the day I day against this ridiculous and fraudulent practice. (what’s more, is how can an NP “specialize” in neurology, psychiatry, cardiology, urology, etc) when THEY HAVE NOT GONE TO MED SCHOOL. Let’s stop the fraud. As for you NPs who are offended by this, I only recognize credible sources. Go to med school, make yourself legitimate, and then we’ll talk. I refuse to seek medical care from a person who has to look at pictures of what I may or may not have on a computer screen, and then have to look up the medication to prescribe, because the picture resembles what I might have. (I should add, I think nurses in a hospital setting are wonderful. I was hospitalized with a serious injury a few years ago, and I could never thank them enough for their compassion. That doesn’t mean I want them prescribing medications that can change your brain chemistry. An NP who specializes in neurology? Yeah, I’m a non licensed pilot but played a lot of video games and did well in the simulator. Wanna fly with me?)

  11. Joe,

    Calm down buddy. NP’s do not want to “play doctor” as you assume. Most NP’s are nurses who have practiced for several years and want to advance their profession. This does not make them frauds. Nobody has more respect for a person’s dedication and perserverance to complete medical school than I do, but that does not mean you have to be an MD or DO to provide quality care. It also does not mean that physicians are perfect and do not make mistakes, because I can tell you they do; and more often than you may think. I cannot tell you how many times I have had to beg a physician to order more tests on a patient (because they were actively having a hemorrhagic stroke, MI, going septic, etc), instead of transferring them to another unit or discharging them home.

    I agree with Dr. Liu’s assertion that a nurse practitioner’s required 600 hours is insufficient when compared to a physician’s 10,000 hours of training, however, most nurse practitioners have worked in the acute care setting for many years. I started my career as a Navy Corpsman (medic) in the military, serving 4 tours in Iraq and 2 tours in Afghanistan. Not only was I responsible for keeping my Marines alive, I was also responsible for providing care to entire civilian populations because their doctors fled the country as soon as the war broke out. I provided various levels of care to men, women, and children who were caught in the crossfire of war.

    As an RN, I worked in the intensive care unit of a Level 1 trauma hospital, where I continued to learn from physicians and nurse practitioners who are some of the best in the business. I worked there for just over 5 years (~10,000 hours).

    Now, as an NP, I work in a busy primary care office where I see up to 30 patients a day. Am I perfect? Absolutely not. Do I feel confident that I can assess, diagnose, treat, and evaluate an individual’s response to an illness or disease? Definitely. I also know my limitations and I know when to make the appropriate referrals to the specialists. These specialists are ALWAYS physicians. NP’s can specialize, and some schools even offer fellowship programs for some of those specialities, however, those NP’s work in physician groups and they do not have the same level of autonomy that a primary care nurse practitioner has (which is what this discussion is about).

    NP’s serve a role in our healthcare system, and their presence will continue to increase. In 2004, there were around 100,000 nurse practitioners in the United States. Now there are over 200,000. Other countries like England, Ireland, Australia, New Zealand, and Taiwan are all utilizing the skill sets of NP’s now.

    Change is coming, Joe…I just hope your doctor doesn’t miss something serious that your NP may have picked up on, after you refused his/her care.

  12. This is a biased opinion. One NP cannot represent the entire NP population. I have a Microbiology Degree and another degree in Nursing. I had a Medical Technologist license (ASCP), RN, PCCN, BLS and ACLS and all my experience counts as clinical experience. When I used to work in the lab where MDs call me to ask me the most stupid questions. I assume they are new to the profession. As a nurse, I am also very frustrated about newly grad doctors who do not know what they are doing and putting patient’s life at risk. Do they represent the entire MD population? Nope. Your article is unfair. Do you really think nurses can do their job without knowledge of pathophysiology and symptom recognition? Most docs miss those and nurses with good symptom recognition is the first one to alert the doctors. The success of hospitalists are mostly due to nurses.

  13. I agree that it makes sense for an NP with significant clinical experience between their BSN/RN and then a MSN or DNP to help with the need for addressing patient’s primary care needs. Especially if they have received mentoring and on-the-job training.

    Here’s my issue with NP training. Becoming an NP requires NO clinical experience between the two degrees. Someone could complete their BSN, immediately enroll in an MSN program, then, DAY ONE after after graduation, be considered to be fit for practicing independently. Are you kidding me??? That’s what I find the most disturbing.

    When I finished medical school, I couldn’t see patients independently (and I darn well knew I wasn’t ready). In fact, I couldn’t apply to get my state medical license until I finished my intern year and passed step 3 of my medical licensing exam. Even then, I had 2 more years of residency and had to pass my FP boards before I was fully ready to be out on my own. On top of that, I have to pass the same FP boards every 10 years and keep up with a huge amount of CME.

    I’m not saying there isn’t a role for NPs or PAs. In fact, during my residency, I have seen many experienced PAs and NPs who do quite good work and, they taught me a lot. But they had years of on the job training. But not all NPs have this opportunity.

    I’m now seeing a lot of NPs straight out of training (with little to no clinical experience b/w degrees) look like deer in head lights. They’re painfully slow, not confident and, they complain when they get overly complicated patients. I thought they wanted to be completely independent. You can’t have it both ways. NPs are not being trained adequately across the board. It’s too hit or miss.

    I pose that NP programs need to be enhanced so a graduate gets the built-in training that’s rigorous enough to be ready to see patients on day one. Right now, it’s hit or miss if they’re ready. It’s heavily based on if they’ve had adequate clinical exposure OUTSIDE of their NP training. To me, that signals a flaw in the program design.

    There is NO substitute for hands on experience and hands on, collaborative clinical problem solving. to build the necessary clinical knowledge base. This cannot be achieved with a program that’s heavily online based and supplemented with a handful of clinical rotations. That’s what the current NP programs offer.

    Here’s my proposal: ANYONE who wants to have independent, non-supervised practice privileges must complete a residency. One that guarantees minimum competencies of all graduates upon completion of the residency. Sure, let NPs have the independent practice privilege (and PAs for that matter) but make them do a residency first. Derm biopsy; Fluorescein stain eye exam; Sutures; Joint injections; Navigating a patient through a Hospice experience; Signing the death certificate; Doing a 3-5 day newborn exam; Knowing pediatric developmental milestones; Guiding parents though bed wetting, feeding and behavioral challenges; Knowing peds derm; Knowing how to deal with in office emergencies etc, etc, etc. We learn a lot in med school but residency is where the real, day to day learning takes place.

    Primary care can fool you. Easy stuff is easy. Straightforward stuff is straightforward. But not every patient has the classical or typical presentation of diseases. That’s where adequate experience saves your butt and potentially your patient’s life.

    Thinking that we can take the shortcut by not requiring adequate training for NPs might look like a quick and cheaper solution to the primary care shortage. But it’s short-sighted and has the potential to create gaps in care for patients.

    Require NPs to get the ALL training they need BEFORE they graduate.

  14. Mid-Level providers basically function at the level of a 4th year medical student with half the intelligence. Sorry truth is truth.

  15. A “mid-level” provider (nurse practitioner) at an urgent care center diagnosed my 13-year old daughter with lyme disease after I took her there because our family doctor said the swelling in her knee wasn’t anything to worry about. The tests came back and confirmed that it was lyme and she was started on treatment right away. If it wasn’t for that NP, my daughter may have had irreversible neurological damage.

  16. As a nurse practitioner for over 17 years, I liked to add to the discussion that anything outside the scope of practitioner is ALWAYS referred to a specialist. We, as nurse practitioners, are not in the practice to just shrug patient issues off. This is where most doctors get this wrong. We want our patients to be well. If we are unsure of a diagnosis, we will reach out and refer. I am truly insulted that doctors believe that we minimize and are undereducated regarding patient care. I truly care about my patients and will do whatever it takes to make my patient well and get an accurate diagnosis. I know my resources and use them if need be.

    Please, use common sense. We want what doctor’s want. A good outcome.
    Eileen

  17. “Nevertheless, if policy makers feel primary care is a job that nurse practitioners free of physician oversight can solve for patients seeking initial care, then they might wish to allow nurse practitioners to expand into another specialty:

    Emergency medicine.”

    Why would you want NPs independently staffing ERs? If you think NPs’ training is not fit to practice family medicine in outpatient clinic setting independently, would you think that they are able to resuscitate crashing patients? I had not attended NP school but I don’t think their curriculum includes intubating, inserting lines/chest tubes, and running codes..

  18. Can’t really believe the comments on here but I am an NP and I have found several things on a patient missed by MD. One was a man with back pain, elevated liver enzymes, microscopic hematiria he had not had work up by his “MD” and low and behold I sent for work up to find renal carcinoma. I also recently found hepatitis missed by MD. I am not smarter or wiser and thankfully the MD I work with does not feel I am incompetent as with two eyes, we seem to help each other.

  19. I became an MD because it’s a noble profession and I love being trusted by patients with their very lives. It’s no small responsibility and should not be taken so lightly as it is by so many “providers” these days. Instead of patients being the focus of our efforts through collaboration, there is this animosity between medical doctors and the mid-levels that is getting in the way. It comes down to knowing you’re place – and all medical professionals have an important contribution to make – but best done by sticking to what you were trained to do. If you trained as an NP then that is what you are and do not compare yourself to a physician.

    This is where I am finding a whole lot of hypocracy in our healthcare system. Mid-level providers now have the opportunity to practice independently – it scares me and frustrates me to no end because of what I had to go through to become an MD. Doctor is a privileged title and I cringe every time I hear an NP or PA call themselves a doctor – most of it has to do with wanting to be perceived as more than they are to their patients. Many will deny this happens but I see it everyday where I work. Patients will almost always assume they are seeing a doctor when they go to a clinic and it’s wrong for a mid-level not to make it known what their training is. This is why – one of our NP’s that called himself doctor began treating patients well above his training because he didn’t want to admit that he was an NP. This is so incredibly wrong and this is where we are headed as long as mid-levels continue to try to elevate themselves to the MD status without the credentials to back it up.

    You forget how much liability is on a doctors’ shoulders – we are scrutinized for everything we do and are made to look bad every time you do something we deemed unnecessary based on scientific understanding, experience and intuition. A patient upset at an MD for not prescribing Tylenol 4 and Xanax together thought an NP was the best provider he had ever seen when the NP went ahead and prescribed these meds that the MD would not for patient safety – 100′s of each monthly. I wish I could say this is a made up example or that it was an isolated event but it’s not. I have seen it over and over. Do you call that a success story? The same goes for antibiotic use – when I review charts I am baffled at how many times they are prescribed without a legitimate reason – at least there was nothing charted that would justify their use. Again not an isolated event – I have seen it hundreds of times.

    I work with NP’s daily – I have trained 10 over the last two years and not one of them was prepared to function independently! None of them knew how to read an EKG, do basic procedures like stitches or I&Ds, interpret laboratory results, how to order the appropriate radiology imaging….etc. The basics of primary care! Even after six months of working in a clinic making 100k they have a hard time making decisions without significant clinical support. We fired an NP because he used google to tell him the difference between a sprain and a broken bone in front of the patient – he didn’t do a physical exam and he didn’t send the patient for an x-ray! Turns out the patient had a broken arm. I understand not all NPs are trained the same but so far I have not seen anything that indicates sufficient competence for independent practice. Many of my doctor colleagues have expressed the same sentiment. Important to note – all of our NPs have been trained at different schools.

    Yes, I am bitter about what is happening in our healthcare system. I am very bitter that a medical student can accumulate 200k in student loans with no guarantee of ever getting into residency because there aren’t enough training positions – and yet with a fraction of the training and clinical experience an NP can practice medicine – and how is that online training is okay? How would it make you feel if your doctor got his/her degree online?? That doesn’t happen and I hope it never will!

    What all of this comes down to is doing what’s best for patients – preserving the art of medicine – being part of making it better, not worse. There needs to be a better definition of roles to improve collaboration of care. I am willing to work with NPs because I think they can do so much for patients – but I won’t tolerate this new entitlement/”I am as good as a doctor” crap going on. Those of you that do this will lose the respect of those that can become your mentor and advocate. Learn your place and stick to it.

    • Agree if “an NP or PA call themselves a doctor” that is a significant problem. Not only is it misleading and false advertising, it violates the fundamental trust patients have in all of us who care for them.

      • I agree with your article and your general statements Dr. Liu.

        I am a PA with 16 years experience. I currently work in Cardiology. While I think that I have enough experience to warrant seeing routine f/u’s and new patients on my own I do not think that I am on an equal footing with a Cardiologist. Will I sometimes catch things that my MD might miss or overlook? Of course. Will I occasionally make mistakes? Of course. While I occasionally save the day? Yes.

        However, I AM NOT A DOCTOR. I DID NOT GO TO MEDICAL SCHOOL; I SHOULD NOT be allowed to practice medicine completely independently.

        Most of the arguments and the supporting evidence that I have read on this thread, from NP’s and MD’s are anecdotal. Obviously there are some not so great physicians and there are some exceptional NP’s. But NP’s ARE NOT doctors. That’s the bottom line. They did not go to medical school. They SHOULD NOT be allowed to practice medicine without a collaborative agreement with a physician.

        If NP’s want to be doctors then they should go to medical school. Enough said.

  20. I might have a somewhat controversial opinion on the matter, as I teach nursing. I do feel that physician extenders are important, but I believe in the collaborative model as it relates to nurse practitioners, and not the independent model.
    I also believe part of the problem lies in the wide disparity in education and the format of delivery in many graduate schools as it relates to the quality and intensity of the theory and clinical piece. If graduate schools of nursing would make the admissions requirements tougher and the required clinical hour piece longer, the quality practitioner might be better.

  21. I am interested to know the correct diagnosis of this patient’s back pain. Which tests, if any, were needed that the NP did not order in her work up? What was so wrong with the NP’s work? I think it needs to be considered that, perhaps, the NP never actually said “micro kidney stones”. There is usually a lot lost in translation between providers and patient’s retelling. If I had a nickel for every upset family member that called because their mom or dad mistakenly told them they had an some awful, serious condition when in fact it was a UTI or the likes. If you’re basing an argument against independent practice of the entire NP profession on a patient’s narrative, it is not a strong argument.

  22. As someone with Crohns, I can’t afford to see anyone less than my doctor. A missed symptom or misdiagnosed symptom can send me into a whirlwind of symptoms that were silent days before. My friend who is a current med school student laments over the fact that a NP license is becoming trendier and she fears she won’t find a job in internal medicine. I think there should be a limit on the number of NPs in the nation. Hard to regulate and insulting to enforce? Maybe. Necessary? I think yes. I’m not paying to see a Nurse and the last time I did, I ended up with hives because she couldn’t grasp that cephrasporin is a cousin to penicillin and I’m allergic to the latter.

  23. Clients prefer NP’s. We are well educated and perfectly suited to the job. Physicians make mistakes too. Sounds like you are feeling threatened. This article is nothing short of hate speech, and you are not exactly a credit to your profession.

  24. Lucy,

    They are not “clients,” they are patients. I went to medical school because I wanted to be sure I had a solid understanding of basic science followed by a solid understanding of pathophysiology. I willingly sacrificed years of my life because I realized that the privilege of becoming a medical doctor also came with it the responsibility of lives. If I was going to take on that responsibility, then I wanted to be CERTAIN I did everything in my power to have the proper fund of knowledge. I don’t regret my sacrifices or my choice, but I simply don’t understand how anyone can feel differently. These are people’s lives we are treating. Routine is routine until it isn’t.

    As for “clients prefer NP’s” if by that you mean “patients prefer NP’s” I can’t completely disagree with you! My 64-year-old mom LOVED her NP …….who has been in practice for over 15 years and was ordering a transvaginal US on my mom’s asymptomatic retroverted uterus every six months. She simply didn’t know that was a normal anatomical variant. A first-year medical student should be able to tell you that. My mom is an elementary school teacher with no medical background. She said she loved that her NP was thorough. ……..I informed my mom that the correct term is called wasteful, and now she sees a medical doctor who DID make sure she had her yearly mammogram (which was missed the past two years despite a family history of breast cancer). My mom’s new medical doctor doesn’t talk to her about how cute her shoes are or what she is doing to her hair…….and he doesn’t order a plethora of labs and imaging….he’s quick and to the point. To someone with no medical knowledge, that may seem unpersonable and not thorough but far from it. First, do no harm. So right, often patients “prefer” the NP, but this is only because they trust the system that they are seeing people who are as trained and knowledgeable as MDs. After all, that is what keeps being said, that NP = MD. When my mom learned she no longer had to have a transvaginal US every six months (which also means she no longer has to pay the copayment for the procedure) her loyalty quickly changed from the NP to the MD. And this is just one example…..I have so many more including my own personal experience.

    Finally, I don’t think doctors feel “threatened.” Threated by what? Our education is sound, and we don’t have to plaster the internet with “we are equal” because our education and training speaks for itself. Physicians won’t be replaced, at least not for long. Maybe appalled or dismayed more appropriately describes the feelings? Why wouldn’t everyone want to be sure they have the highest education and training before they practice independently? You don’t know what you don’t know……If you want to treat patients independently, then care about them enough to be willing to sacrifice things in your life to thoroughly educate yourself from the basic sciences up (bc a fundamental understanding of science does, in fact, help you understand disease processes). Learn that which can’t be taught in a two-year degree and certainly not online. Don’t just pass step 3 but pass steps 1, 2, and 3. They are all important. Important for our patients and that is what should matter. At least to me that is what is important……I naively thought everyone felt the same way.

  25. The big problem is only 2% of medical students are going into primary care, while the others specialize. To me this makes sense because student loans are killing new MDs, and they can make a lot more in a specialty. This is what the medical community need to figure out and change. The 21 states that have passed a form of independent practice for NPs is because of the primary care shortage, not so they can do hip replacements

    I am a nurse practitioner and worked as an RN for a decade in level one trauma centers. I do not doubt that most doctors understand pathophysiology and diseases more than most nurse practitioners. The school I attended also had a large medical school, and many of our classes were combined with medical students. Part of this was to get us to understand the others profession. Great for NP students, but it was pointed out in some lectures they wanted to break doctors tunnel vision. For decades medical students were trained to look for and treating the disease, but they failed to see and treat the whole patient. Nurses are trained at seeing and treating the whole person, which is probably one reason that for 40 years nurses have ranked first in honesty and ethics (except for 2001 after 9-11 when it was firefighters).

    The MD I work with and myself consult often to specialists and people we know. They are also open-minded to what is the best for the patient.

  26. I am a masters~ prepared RN with 32 years of experience. I have worked as an instructor at the University of Michigan School of Nursing and the University of Michigan Medical Medical Center. First and foremost, we need to stop attacking each others’ credentials as mutually exclusive. I have seen mistakes made by both NPs and MDs.

    I think it is import for large metropolitan Drs ti understand (Davis) that more rural areas in midwestern states have a real shortage of all physicians right now. This is not anecdotal; there are literal thousands of studies you can find on line. I myself recently moved to northern lower Michigan and started practicing at a local in~home hospice agency. Within two years, I became so frustrated I started sending my patients down to UMMC for care. Then my health started to decline and I could not find a Dr or a NP who would listen empathetically or just order some tests other basic labs. There are no neurologists here. After 2 yrs and a formal complaint against a NP in a local hospital, my own diagnosis was finally taken seriously: ALS.

  27. I think the idea of primary care was changed away to its true definition. Upon looking it up, primary care is health care at a basic with an initial approach from a doctor or nurse for treatment so it means the one who should be giving consultations are the ones who has a wide range of knowledge on such field.

    It is safe and assuring to say, I think it is better to have the care from nurses with physician oversight to fully cover what is to be taken care and the right treatment to be applied. Person responsible for health will be the one with the license of your ailment.

  28. I can see the frustration on both sides: MD’s and NP’s. NP’s are wanting independent practice for the patients in rural and under served areas. In these areas patients are traveling 2 hours for medical treatment. United States law makers want to offer these residents medical care through NP’s. Honestly, NP’s are not looking to over take doctors’ jobs, but they want to help our growing healthcare needs.

    Nursing school, NP school, and experience versus medical school , residency cannot be compared. A medical doctor is a medical doctor and I respect their dedication. A nurse practitioner is an intelligent nurse with an advanced degree and experience, which is to be respected as well. Both professions bring different experiences, but possess the compassion and commitment to safely treat patients. Doctors consult nurses on the hospital units daily and nurses consult doctors routinely. We work as a team.

    As a new FNP, I can safely exam, prescribe, and treat less complicated primary care patients. I do not wish to replace a doctor in complicated, tertiary cases. I refer patients routinely to their PCP or a specialist if it is out of my scope of practice. I understand my limits. I pursued my MSN-FNP to help bridge the gap in healthcare, not to compete with another well respected discipline.

    Like all professions, both NP’s and MD’s have colleagues who do not practice quality care or made errors. Please do not degrade the entire disciple/profession, because of a colleague’s poor judgement, a simple mistake, or personal (or someone else’s) experience. No amount of education or experience can guarantee perfection in healthcare. As a nurse and as an FNP, I have noted many errors on physical exams, diagnosing, treatments, documentation made by both disciplines. We are not perfect, that is why healthcare has always been a team. Let’s work together as a team: MD’s, FNP’s, and PA’s. There is plenty of work!

  29. I am 50 years old and have had two HORRIBLE experiences with NP’s. The first was when I stupidly allowed on to do a uteran biopsy on me. That resulted in excess bleeding, pain and even after the suggested rest period I collapsed in my garage due to what felt like a knife in my lower abdomen. NEVER again. My OBY/GN performed the previous one without a hitch..The second mistake was allowing a NP with only 600 hours manage my psychiatric medicines. My gut told me no, but I took a leap of faith and I should have known better. She had no idea of what she was doing and didn’t even know how to call in 3 month supplies of medications to Express Scripts. She was rude, acted like a know-it-all and dangerously dropped mgs on a controlled substance I am taking. As I said, NEVER again…I am going back to my primary MD who I should have never left. I respect nurses, nurses aides and NP’s – to the degree again that they know their place and do not go parading around like doctors. Only 600 hours of experience past the 4 years of RN? It take 1200 floor hours to get a state beauty technician license. For basic things under a physician’s supervision I think NP’s are alright. However, I do not believe they should be diagnosing, or having the freedom to write prescriptions without the approval or consent of a qualified MD and DEFINITELY they should NOT be able to perform internal procedures at ANY COST. If they want to be doctors, they should go to medical school and pay their dues like MD’s do. I see a lot of ego there and I’ve seen an NP allowing patients to call her “Dr.” and not correcting them..There is no shame in being a nurse, an aide or an NP as long as you don’t overstep your bounds. Not all MD’s are good either, but after these two horrific episodes with NP’s, I will never allow them to manage my health again.

  30. Unfortunately, during my FNP clinicals I heard NP’s and PA’s referred to as “Doctor” by patients. Sometimes no one corrected the patients and that was very strange to me. Patients see anybody wearing a lab coat as doctors. We as clinicians should enlighten them about the different types of providers in healthcare and definitely correct them.

  31. I completely agree with everyone (whatever that even means), but I can see both sides of the argument. MDs, PAs, and NPs are all primary care providers. Who would I trust the most with the amount of knowledge to treat me? An MD, but PAs & NPs serve their purpose. It’s important that they do correct patients and inform them that they are not physicians nor do they hold a doctorate degree (with the exception of DNPs). As a doctor from a different discipline, my classmates and professors often had this discussion. How do you make sure that people understand you aren’t a medical doctor, but still a doctor in a different discipline? NPs and PAs do not have the right or privilege to call themselves “doctors”. They didn’t do the research or publications to be called an actual scientist or expert. I find it just as surprising as anyone that it only takes a few years to become an NP and to find out that some states are allowing NPs to practice independently, yet PAs can’t. I understand nurses have a very strong union, but it’s getting ridiculous. You are a primary care provider, but not a physician so introduce yourself as such. “Hi, I’m (first name) the nurse practitioner or physicians assistant.” If you have a doctorate in nursing practice, then say, “I’m Dr. (last name) the nurse practitioner so they know your discipline/specialty. Healthcare is complicated and to your average person, white coats are doctors (no matter how long or short the coat is) and everyone else in scrubs are nurses (not CNAs, MAs, RTs, etc.). What the average person doesn’t know too much about is that there are doctors with different disciplines like medicine (the most common doctor and obviously the highest paid), optometry, dentistry, psychology, physical therapy, audiology, pharmacy, and so forth. Many of us often introduce ourselves as “Dr. Blank, the audiologist or psychologist” because we earned that title in our respective fields. This particular situation reminds me of the hierarchy within mental health providers: the psychiatrist (med school trained doctor and can prescribe medication), then the psychologist (PhD or PsyD type doctor and can prescribe in some states so far), then the wide array of therapists/counselors/LCSWs (all different approaches to treatment, but can’t prescribe, works under the latter two, and can’t perform all assessments/screenings.) Each serve their purpose just like primary care providers and some patients/clients prefer one over the other depending on the individual. It all depends on what they need really, and who they most feel confident with, but I believe this is what helps…contract/consent forms. Before seeing a mental health provider, the consent form and terms of agreement involves the education and background of the provider, what they are trained to do, and their approach to treatment. If it matches with the individual being served, then great. Far too often, primary care providers can look the same (scrubs or white coat with a badge) and they won’t even introduce who they are and what they do so the patient automatically assumes “physician” when in reality, it could’ve been anybody! An MA, CNA, RN, NP, PA, MD because they all wear the same uniform and don’t even bother showing you their badge or introducing themselves at times. Medical care needs to be clear cut! Show me your credentials and what you were trained to do and I’ll decide for myself if I want to trust you with my health even if it means seeing an MD, PA, or NP for my primary care. To be honest, it’s not about MDs feeling threatened. It’s about being on equal footing. Would NPs be appalled by the idea that maybe one day nurses (RNs) won’t even need a masters degree to “do what 80-90% of what NPs do”? Or be able to practice independently? What if the RNs that went to get their ASN (2-year degree) thought getting their BSN (additional 2 years) was adequate enough to do what NPs do should that ever change? The tune might be different for NPs saying that MDs are threatened when they realize they did more schooling, paid more tuition, completed more clinical hours, only to have RN-BSNs think they’re on “close to” equal footing as NPs.

  32. Hi Dr. Liu
    I am currently a Family NP student right now. I have a big respect for the primary care specialty and I understand how difficult it is to become an expert in this setting.

    That being said I also understand the knowledge that MDs have and the rigorous education that you guys obtain. So I agree that oversight is definitely needed. (I am saying this from my own perspective and no experience in the field). There can be a million things that a primary care provider must be able to discern for the patient and without the proper education it is an extremely daunting task.

    My question is even with MD oversight, after many years of experience do you think an NP will be able to practice independently eventually?

  33. One, physicians don’t own the term “doctor.” Doctor is a degree. Did you sit in class and correct your history professor when they referred to themselves as Dr. So and so? No. Do you tell your dentist not to call themselves Doctor. No. Doctor reflects a degree obtained not a profession. You are a physician or medical doctor. If you have your doctorate in nursing, then saying, “my name is Dr, John, I am a nurse practitioner” that is appropriate. If you have your doctorate and refer to yourself as such, that is not misleading. Somewhere along the line physicians hijacked the term and think it belongs to them. They view a prestige with the term and think they are the only profession worthy of using the title. I don’t get confused when I see my dentist, and think “wait! I thought you were a dentist, I didn’t know I came to my physician’s office!”
    Two, 10,000 clinical hours is arbitrary. Healthcare has to be evidence based, and there is no evidence that suggests 10,000 clinical hours is necessary to provide competent primary care. As a matter of fact evidence suggests the contrary. Many, many, many, evidenced based, peer-reviewed, systematic reviewed studies have shown NPs provide as good or better care in the primary setting when compared to MDs. Furthermore, at 20% cheaper. This is not due to lower wages either. This accounts for costs associated with unnecessary testing, over medication, preventable hospital admissions, etc. NPs are statistically more likely to prescribe changes in lifestyle/habits before medication management of illness when compared to MDs. Compliance is greater as well. Most likely a result of an education with a larger focus on patient education and interview techniques which assess and focus on psychosocial influence of disease and wellness. Studies show that utilizing evidenced based, deliberate, scientifically developed methods such as motivational interviewing (which requires practice and is not necessarily natural to most) is far more effective than reliance on “well I am just good at talking with people” or ” I’m a natural leader or charismatic.” Another aspect of most NP curriculum. All of which are extremely appropriate for primary care. Essential I would say. All of this anecdotal evidence is the lowest form of evidence and is useless in a scientific discussion. Any provider who makes judgements based on such is irresponsible and unsafely over-confident in their own, biased reasoning. Evidence based is evidence based. It often yields counter-intuitive, unexpected results. We designed the process that way on purpose. If it did not then there would be no use for it, and as it stands, it is the cornerstone of good medicine.
    Three…what is really going on is that there are a bunch of people, who are butt hurt at the fact that someone can do the same job without having had to go through the same process or spend as much money. I am only talking primary care here. It’s the thought of “how dare they! They have the audacity the suggest that they can do the same job as me! I did four years of medical school, 3-4 four years of residency with 10,000 hours of clinical! How is it possible to say you are as qualified or close to equal?!” With a little bit of the “its not fair” response mixed in. That argument sounds logical. Unfortunately evidence disagrees. If you chose primary care then thank you. You are needed, but perhaps you’re overqualified. In emergency, inpatient or specialized medicine NPs are not as qualified. No question and supervision is needed.
    Another likely realistic aspect contributing to the attack on the profession has to do with your ego getting hurt. Many MDs perceive that an NP even suggesting they can effectively perform as well in primary care is insulting to their profession. Because after all “I’m a doctor,” and at least part of the reason you became one is so you could say that.
    I don’t think NPs think they are on close or equal footing as MDs overall, but in primary care yes. MDs are restricted with resouces and liability in primary care and cannot practice within their full scope in that setting regardless. You cant run a code, diagnose or treat stroke, treat MI, or any other life threatening emergencies in a physician’s office. You all refer out for that anyway! “Send em to the ED!” All they have to do is recognize that “maybe something emergent is happeneing here.” And guess what…the ED physician won’t care about any of your work up at the office. They are going to order their own tests and do thier own work up from scratch. Even they won’t rely on your expert diagnosis or concerns. Even when someone has abnormal labs they are told to go the the ED for a workup. I’m not saying primary care isn’t a noble place to work, It is probably the most important arena in healthcare. It should be a place for health promotion, disease prevention and management of chronic illness and minor acute illness. All of which are well within the scope of NP practice. The main motivation here is the butt-hurt effect, mixed with monitary incentives (the reason why MD don’t fight NPs ability to prescribe outrageously serious medications such as insulin and BP meds but have a HUGE issue with narcotic prescription, which rarely yields accidental overdose, and is again less likely to be prescribed by an NP) This is all masked by trying to claim patient safety, meanwhile evidence proves the argument is wrong. Furthmore, we have this massive need for primary care which MDs don’t seem to want to fill anyway. There is a continued trend of less MDs becoming PCPs, but you also will fight to the bone that no one else dare step up to the plate. All the while yelling “it not safe for the patients! Think of the patients!”

    • Agree that context matters and this is appropriate – “my name is Dr, John, I am a nurse practitioner”. However, I don’t always see that in practice and I only have to wonder why.

      Yes articles have said NPs provide similar care at lower costs. However, those are for easily measured areas of preventive care and predictable algorithmic care such has chronic conditions like diabetes, high cholesterol, etc. When it comes to diagnostics, i.e. patient comes in with abdominal pain, chest pain, rash, things that don’t neatly fit in an algorithm, I haven’t see articles which demonstrate NPs have decreased costs due to “unnecessary testing, over medication, preventable hospital admissions, etc.” and would like to see it. My experience that NPs do not do as well in these areas of clinical ambiguity.

      The 10,000 hours was referring to getting better at diagnostics which is a cognitive skill. 10,000 hours of just clinical hours is not the same as 10,000 hours of deliberate practice of getting better. When getting to a diagnosis, I always wonder afterwards, was there a better and faster way to get to the right diagnosis if I had asked this question, ordered this test, done this exam? Was it possible I ordered too many tests and where they needed?

      As part of their training, family physicians focus on the whole patient including psychosocial influence and motivational interviewing.

      • You are referring to anecdotal evidence in terms of “in my experience,” which is all but useless as humans tend to remember examples of information that support what they already believe. Again, that is the purpose of evidence based to minimalize human error and bias. Additionally, as a nurse practitioner those same questions are always asked of one’s practice and always should be. The nurse, the physical therapist, the occupational therapist, the physician’s assistant etc all ask, “Did I do the right thing, etc.” So to imply that process is unique is to physicians is egocentric. My point with the 10,000 hours is that more is not always better and an experienced NP will naturally accrue the same experience, so 10,000 means no difference over time. Why not 12,000, why not 9, 15 or 20? How was 10,000 determined ? If more is always better why not more? All practitioners will get better over time (hopefully) but when do we say its safe to do it alone? Evidence. Evidence must drive all decisions and to disregard it simply because “well I disagree because I don’t believe it.” or “I disagree because even after 10 years I still am not always sure, so how can you be after a masters or doctorate?” The answer is, you never will be sure. At least I hope not. In 10 years you should question yourself, in 15, 25 and so on. Its your job to. The point is, when does the benefit out way the risk? When are you safe enough to help more than not? Unfortunately that’s the reality. Furthermore, across the board is several other studies, states that have less regulation and allow NPs to practice without restriction have better health outcomes and overall health. Admittedly all of the research makes it difficult to attribute a causal effect, however, its an interested and consistent trend. Something that does have a direct correlation is that states with greater restriction have less NPs in primary care and more employed in hospitals. This is attributed to the difficulty of obtaining written collaborative agreements, contracts determined by physicians that favor physician interests. Namely monies distribution. As in paying a physician to “review” your documentation periodically for a substantial sum of thousands of dollars. A “review” which typically involves a quick signature. Furthermore, your reference of “oversight” in the real world is a joke. Laws in all states do not even require a physician to be present at an office for diagnoses or treatment of patients. So I’m here as an NP under your “supervision” working in the office on a Saturday, because my physician doesn’t want to see pts on a Saturday treating and diagnosing by myself, but this is ok because a physician is my boss and signs off on documentation and treatment that has already occurred. On a day that the physician is working the same hours as the NP every now and again a physician may pop in at the end of a visit to “concur” treatment and maybe reassure a pt because now the doctor agrees. Really the purpose of this pop-in is so that the visit can be billed as “incident to” to get 100% medicare or Medicaid reimbursement as opposed to the 70-85% the NP would have been reimbursed had they seen the pt alone. Therefore, restricting NPs is restricting primary care, arguably the highest needs field in healthcare. The whole thing is a joke with conflicts of interest driven by monies and ego.
        Coming back to the 10,000 hours…your article did not say, “new NPs should not practice primary care”, you were speaking to the profession as a whole regardless of experience. An argument that NPs should have oversight when new to practice could be made, however oversight should not be done by or at a minimum, limited to a physician’s oversight but provided by more experienced NPs. We could even use the arbitrarily selected 10,000 hours of practice before being independent (which evidence of over 40 years has shown to not be additionally beneficial). NPs have a unique body of knowledge and need to be regarded as such and any nurse practitioner who does not believe that is only hurting the profession.

  34. The biggest argument, as you mentioned, is NP training hours are less than one of three years in medical school residency. I believe NP’s should have physician oversight for the equivalent of four years in primary care then be allowed to work independently. In FNP school we have to demonstrate role preparedness and a differential framework of thought to rule in and rule out. I will be graduating next week and realize my training has equipped me to be a safe entry level nurse practitioner. I agree you don’t know what you don’t know. I look up anything unfamiliar and utilize quick references when needed like UpToDate, and do study questions from NEJM FM board review for continuing education. Thanks for your thoughts.

  35. I had a sudden, severe sore throat, and went to urgent care where I was seen by an NP. When my instant strep test came back negative, she proceeded to GOOGLE my symptoms (to no avail), performed the lab strep test, and sent me home. When my conditioned worsened, I returned and saw a different NP two days later. She couldn’t locate my lab strep test results (“this NEVER happens!”) but put me on antibiotics because it was “probably” strep. Three days later I went to the emergency room at Massachusetts Eye & Ear Infirmary, where an otalarynologist diagnosed me (in about 2 minutes) with shingles of the larynx. So, I went 5 days without treatment for shingles because 2 NPs were busy googling my symptoms and unable to locate test results to confirm their diagnosis. Shingles is no picnic; try getting them in your mucous membranes. I got so sick I lost 20 lbs in 3 weeks and will likely have nerve pain for months longer than I would have had I been diagnosed and treated in a timely manner. NPs are NOT doctors.

  36. As I began reading this article I noticed you start with an anecdote of a NP failure. I understand what you were trying to present, but I’ll bet that most people have at least one horrific story of a MDs practice that is based in lack of knowledge or a failure to accept just that.
    Further into the article I was surprised to see one of my favorite authors mentioned, Malcolm Gladwell, as he will usually embellish facts with his great storytelling. I was even more surprised that you would use the 10,000 hour rule as this is a much debated topic and one I would recommend you read about before using again.
    I also noticed that NPs prior experience was not noted. I can only provide personal experience here (majoring in public health), but I have yet to meet an NP student who hasn’t had many years if not decades of experience with direct patient care. The AANP states that the average age of an NP is 48 and has been in practice for 12.8 years which means they started a NP program in their early to middle 30s. The traditional BSN student graduates at age 22, do the math.
    NPs, just like MDs, practice within a certain area of medicine for which they have education and training. Knowing your limits is key and it comes down to clinical judgement and decision making. Have you never asked a colleague for input?
    I didn’t see any mention of the evidence surrounding patient care outcomes of MDs and NPs. I’m sure you have access to academic journals and most likely know where the evidence points. That being said, I’m going to call this article what it is, propaganda. This article is nothing more than a bias opinion to protect your occupation. I’m not trying to attack you, this is genuinely how I feel.
    I believe MDs have more in depth knowledge than NPs in many areas, but I also believe that NPs have enough education and training to provide care equal to that of their MD counterparts in the specialty for which they have education and training.

  37. I was a CNA for 4 years, LPN for 6, RN FOR 10, bsn for 3, msn for 10…had certifications in ICU, med-surg, ER, rehab etc. I have worked with numerous doctors and fellow NP’s. Here is the bitter truth. I wouldn’t want to work with a nurse practitioner that graduated from an online university. I attended a rigorous program at UTMB. It’s pathetic when I hear that NP student’s have to find their own clinical site and preceptor. Would you let a medical doctor than studied medicine online and found his own preceptor in a local clinic treat you. Lets be fair. NP programs should be limited to universities with teaching hospitals only. MD anderson is now offering 1 year residency for new NP’s. That should be the future.

  38. The statement you made about NPs having 600 or less total hours of practice is not accurate. I am currently in NP school and have came up through the ranks, beginning as an LPN, then RN Associate Degree, then BSN, and now NP. This has been over the course of many years and now my 4th nursing program. Although I do agree that there are certain things only physicians must do. Nurses are trained to treat patient holistically. We look at EVERY thing about the patient, including their families. I believe NPs have their own place in health care and have the education and training to make assessments and perform skills. Our whole nursing career is based on learning to assess. You must look at the individual provider, as there are some MDs who are reckless and practice dangerously, just as there are some nurses.

    • Working as an RN doesn’t count as “medical training.” RN’s who practice for 40 years will have more hours as newly graduated neurosurgery physicians, and one of those two groups will be more prepared to practice medicine.

      Also, downgrading the medical approach in comparison to the holistic approach sounds good until you actually understand medicine, and then you will realize it makes zero sense. MD’s and DO’s are at the top of heirarchy for a good reason, they have the best critical thinking skills, undergo the most scrutinized training and education, and have always provided the best standard of care. Personally speaking, if a family member of mine was truly sick, I would not trust their medical health to a person who only had a couple years of “advanced education” and ~700 hours of training (which could be completely online). I have personally seen newly graduated APRN’s who should be fully competent and ready to practice but couldn’t manage a simple influenza case. Contrast that with newly graduated MD’s who by the time they graduate residency, are ready to practice independently and provide high quality of care from Day 1.

      Lastly, it seems as though APRN’s want a shortcut into practicing medicine without going through the rigors of medical school and residency. My advice to aspiring APRN’s: if you aren’t happy with the current scope of practice of APRN’s and would like more autonomy, the appropriate route is medical school. Apply, get accepted, graduate, go through residency, and then you will achieve the “respect” and privileges that you so want to obtain.

  39. Dr Liu’s comments provide a wonderful opportunity for defining the role of the primary care provider(PCP) and inviting the question of how do we prevent a watered down version of quality health care in the face of highly coveted universal coverage (ala Obamacare) For starters, 10,000 hours does not typically correlate with the number hours medical students spend learning how to listen to patients, or adhere to illness scripts, or be guardians against poly-pharmacy. Instead, those hours are spent in information packed course work and in cramming for the USMLE- ultimately vying for a coveted spot in a sought after residency. It is, obviously, the goal that a resident will gain extra insight in a 3 year apprentice program – guided by a gifted chief resident. As a 30 year veteran BSN, who was accepted and attended 1.5 years of medical school, I must agree- nurses are not doctors. By virtue of anatomy lab, bio chem, histology, and neurology- our education paths are divergent. I am fortunate to have been accepted in an FNP program which is carefully designed to heighten the level of expertise obtained in the profession of nursing and create a qualified APRN candidate- capable of treating patients in a family practice setting. When I conclude my FNP curriculum, I will have at least 840 FNP clinical hours. Combined with many years in the clinical setting as a professional nurse.

    Aside from the “my hours are as good as your hours” argument, If you believe anyone can follow directions on Google maps, then you must agree that concept mapping does not require 2 semesters of pathology. It does, however, require a full collaboration between the all powerful AMA and the good stewards of APRN and PA curriculums. In order for everyone to be on the same page, we should avoid a share cropper approach to primary care, where the landscape is dotted with some excellent and some unscrupulous MD’s – all of which have the opportunity to cash in on farming out of APRN providers. Instead, we should initiate a come-to-the-table approach and follow the lead of amazing faculty like Dr. Catherine Lucey at UCSF school of medicine. Teaching the concept of illness scripts to anyone who will listen. (Coursera- free)

    I did notice the deadline for doctoral degrees for all APRN/NP’s was quietly moved from 2015 to …a little later on or TBA. As an RN, soon to be FNP and a former medical student – I do not believe adding more letters to my name is the best or only answer for bridging the gap between MD and APRN. I do believe that creating a universal code of practice- used by PCP’s nation wide is the best way to serve the greater good. One language- one practice – multiple practitioners.

    There are changes afoot which should signal the AMA to create a dynamic partnership with PA’s and APRN’s who serve as primary care providers. APRN curriculum is evolved and uses the same evidence based practice theory that MD’s or DO’s use. USPSTF is the benchmark guideline used for FNP’s and Family Practice MD’s alike. The Accountable Care Organization (ACO) business model has identified the financial opportunity in streamlining healthcare to a diagram where the PCP is the center of the patient universe.

    Therefore, I challenge Dr. Liu and others to consider the benefit of a team approach and leave the patriarchal model of medicine behind. In the meantime, I will pray for a kind and gentle physician overseer in the state of Georgia where I will soon be deemed qualified to practice as an FNP (presently NOT one of the 22 states with full prescribing authority or even one of the states with reduced prescribing authority). This information was obtained from AANP. https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment

  40. I am a statistical/computational geneticist by training.

    I received terrible care for over six years from two separate nurse practitioners. I was taken back by how little they knew of even basic physiology, anatomy, and disease pathology. I am very concerned about the state of health care in this country; this profession (NP/PA) serves no purpose to society. They categorically do not have enough education and training, and it is obvious that there intelligence simply is not on par with an MD. Enough PC nonsense, this should be obvious. If you want to be a physician, and you are not intelligent or capable enough to get though medical school, please stay out of medicine. All we are getting is less qualified health care providers.

  41. The fact that NP are independently acting in the role of primary care physicians is a symptom of a broken health care system. I am an adult nurse practitioner who went through a prestigious direct-entry nurse practitioner program. For those unfamiliar with such programs, students without a nursing background spend 1-2 years obtaining an RN, then 1-2 years earning a MSN and being eligible to sit for a nurse practitioner certification exam. Yes, you read correctly 1-2 years!!! There are very few residency programs and they are not required to practice. And then we are off to practice! In an ideal world, we would at least get a couple of years on-the-job training to hone our skills but that often doesn’t happen. Nurse practitioners are wonderful at doing what they were meant to do- treating ROUTINE illnesses and promoting health IN CONJUNCTION with an MD. We are not trained to handle medically complex patients and definitely not in the absence of a collaborating physician! It is sad that many NP’s start functioning as primary care physicians because medical students choose other, more lucrative specialties. Most do this not because they are greedy, but because the cost of medical training (which, unlike NP school, requires many years) leaves them with six-figure debts. We need to find a way to make primary care a financially feasible specialty for medical students so that primary care can be administered in a way that works for patients and providers alike!

  42. I have been a practicing FNP for 2 years now. In my state, NPs do have independent practice, but only after a 2 year supervisory period during which a majority of charts have to be reviewed by an MD or a nurse practitioner with at least 10 years of experience.

    Yes, in medical school you get a residency, in which the oversight and mentorship is likely superior to what I received in my first 2 years of practice. I will admit that upon entering practice I felt woefully unprepared to have the health of patients in my hands (remember I was in a supervisory period where all charts were reviewed). However, factoring in several years of experience, I don’t see how you could say that the ability of a doctor to provide primary care is any different from that of a nurse practitioner. What has the MD who just finished a residency seen, that a nurse practitioner who has been practicing independently for 10 years has not? I had a supervising NP with 10 years of experience and a supervising MD with 35 years of experience. They were both excellent providers, and his ability to provide good medical care to his patients was NOT superior to hers, in any way.

    I also speak as a nurse practitioner who took over the patient panel of a DO, and have seen some of the ridiculous choices, overprescribing, and unnecessary referrals to specialists that this particular physician made. For example, she performed extensive testing (arsenic testing, referrals to GI, the list goes on) on an 84 year old woman with renal failure, based on a total bilirubin level of 1.4 with no symptoms. Of course, I would never judge her entire profession based on this judgement…

    I understand the concern that many physicians express here, but making generalized statements about the capability of a doctor, based on their degree, versus that of an experience nurse practitioner is shortsighted.

  43. We need to protest NP diagnosing, and prescribing medicine., and have this bullshit abolished, for the sake of our safety, and preserving the established excellence in medicine, and treatment in our country by esteemed doctors.

    Just thinking about a NP diagnosing me, without sufficient training, or medical school, just makes my blood boil. The health care profession is playing with people’s lives, instead of finding solutions to the dearth of Doctors.

    My question is, why is there a shortage of Doctors, and how can we resolve this issue without degenerating the entire health system?
    Perhaps if med school was more affordable, that would help some.
    Even efficient computers should help , by getting more done in less time.
    I believe today, with computer technology, it’s possible for a doctor to check several patients simultaneously, diagnose, and have the NP attend to them.
    There’s other solutions , but settling for a nurse who isn’t fully qualified to act as a doctor, shows apathy towards human beings. And you probably know that the less fortunate will are the ones forced to deal with NP’s, and the rich get qualified doctors caring for their health. Who cares about the middle class and poor shit? They are sending a message that their health is not as important as those who can afford a qualified doctor.
    We have to stop this from happening.
    Don’t accept NP’s: Demand to be treated by a doctor.

  44. You are not even an American! Foreign people come over here to make money and then have the nerve to criticize out health care. I am a PhD chemist. I saw a NP by accident and after that, decided I would only see NP from now on. All have been highly trained, skilled and have longevity of practice. You are arrogant and wrong!

  45. I have been a NP for 12 years in primary care. I am in a state which allows independent practice. I ran a satellite office for four years by myself. I had a pediatrician who would come in for newborn checks two afternoons per week only and we alternated well checks until the child was two years of age at my insistence. Your discussion fails to address that most NPs are accustomed to working in a team as RNs prior to becoming NPs. This is an advantage. I can’t tell you how many times, I would see physicians trying to care for things that they had no business treating. I know when to ask for oversight. In my previous practice, we hired H-1 physicians as we were listed as a non-profit. Many unfortunately could barely even speak English and had difficulty obtaining an accurate history, so your article is crap. 90% of the diagnosis in primary care is getting an accurate history. Many of the MD’s then would order costly unnecessary testing, because they couldn’t understand the patient. I was in a group of 17 providers for 10+ years prior to starting my recent position. As far as the patients choosing to see me, out of the 17 providers in our group (8 MDs), I was in the top 3 in productivity and the other two were PA’s. We worked as a team, and this business of trying to bash NP’s (which by the way are mostly female), needs to stop. You should be ashamed of yourself.

  46. “The Bio of Davis Liu, M.D.

    Davis Liu, MDHi!

    Thanks for coming to my blog!

    I’m currently the Chief Clinical Officer and Head of Service Development at the start-up Lemonaid Health. We are intensely focused on make care super convenient, quick and easy, and inexpensive by providing care via app or website. We currently provide treatment for simple uncomplicated primary care issues like acne, bladder infection, birth control medicine, heartburn, hair loss, and sinusitis among others. We look forward to making more services available as we expand to more states.”

    —complicated stuff right here folks…….many years of specialized training for acne, heartburn and hair loss treatment…..LOL….no further comment needed here.

  47. Sorry if this upsets anyone, but I am very scared having these people unattended. I have no medical degree, yet I have been much more knowledgeable then any nurse or PA I have ever encountered. Just last month when I had a sinus issue with swelling she proceeded to give me 7 days of Cefdinir after telling me Levaquin is the first in line antibiotic for sinusitis which is 100% false. (Well, I guess it would be if I wanted tendinitis or other antibiotics have previously failed.) After I finally convinced her to give me the correct antibiotic, since I couldn’t do Amoxicillian, she then only prescribes the Cefdinir for 7 days. Now for a sinus infection the MINIMUM time on Cefdinir would be 10-21 days NOT 7 days. I knew that, but she for some reason didn’t and had no clue what she was talking about. Needless to say, I finally made it back to my doctor in the same practice and he was shocked that she would only prescribe for an issue like that for 7 days and of course wrote me a second prescription for the rest of them (which I had to pay for twice.) He then said he would speak to her and explain to her how to prescribe antibiotics for a sinus infection.

    Even worse was an NP one day saying that she had never heard of discontinuation syndrome or withdrawals from people on SSRIs and it doesn’t cause dependency which is a very dangerous misrepresentation of those medications to the patient. If you have no clue how they even work and what the severe side effects could be then you have no business writing prescriptions. At this rate, anyone could just go off the street and become a midlevel provider. What was even more appalling was during the same visit, a lady was sitting there doing nursing duties (checking bp and blood sugar ect) who turned out to be an X-ray tech! I was horrified when I figured it out and there was no doctor present at all at the clinic. It was shocking and completely out of control.

    As a patient, I have lost complete respect for nurses over the years. They want to play doctor yet every single one I have ever seen has given me false information or have not had the first clue on what they were talking about. Then I magically see a doctor and he understands exactly what I am talking about and the issue so I can get the correct treatment. And the way I see it as a health care customer, aka patient, is that NP or PA visits should only be half the price because you are only receiving half the care. I hate to sound rude or disrespectful in any way. I know they try, but after repeatedly being misdiagnosed and mislead by non-doctors, causing a delay of real care, it has really shown me that are not qualified to play doctor.

  48. I’ve heard many people referred to as a doctor and they do not have a degree in medicine. Only MD’s make a federal case out of being called a doctor. So, the next time I heard someone call my pastor doctor, I’ll be sure to correct them and tell them only people with medical degrees can be call doctors. The way I look at it, if you do the schooling and receive your doctorate in any form of education, you are entitled to be called a doctor, period!

  49. After reading over all of the comments I felt compelled to comment myself as this single post has generated a two year debate. The ongoing struggles between mid level providers and physicians grows stronger as payer systems shrink and the cost of education rises. At its core, the art of medicine is now an evidenced based conglomerate which has been marginalized by a database that can be accessed by anyone including physicians, midlevel providers, and even the layman. I feel like it has convoluted and blurred the lines to a point where a new struggle has emerged trying to figure out who runs the show, who should be paid the most, and who should call the shots. I, like many here have seen both sides of the spectrum in regards to quality of care which is affected by many aspects including demands of institutions, apathy towards ones profession, and lack of knowledge. One thing that has stuck with me over the years is something a seasoned colleague once told me and is echoed by the NYT article: The more you know, the more you realize you don’t know. We can all benefit from that fact. My training was at a university level and mutual respect was common practice but there is always an unspoken undertone that I think you can feel. We all want to be the best and while doing work that oftentimes requires a level of confidence, I believe it is unavoidable not to have confrontation of ego and an ability to believe that your plan is the only plan. Nonetheless I routinely perform many of the skills that have been outlined above not limited to emergent resuscitation, intubation, etc. my training did involve I and Ds, Central line placements, developmental child care, preventative service management, psychiatric care, to toenail clipping for routine foot care. I think a skill set is important but it’s important to note that we can teach a monkey to perform a skill. I do agree that a strong base in physiology and more importantly pathophysiology and an avoidance on the reliance of diagnostic tests does allow us all in the profession of providing quality of care clears way for the construct of medical care. I do believe too however that experience and exposure to multiple versions of the same thing and atypical presentations are very valuable in being a well rounded provider. I am hesitant to say which side of our debate that I am part of so I want to leave that part anonymous. I will say that at the end of the day, no matter what profession you have decided to undertake (physician vs nurse practitioner vs physician assistant), make sure that you understand that your limits are defined by your understanding of basic knowledge of biological science coupled with the experience you have gained based on the environmental diversity that atmosphere can provide. I hope this conversation will continue with a less callous approach on both sides of the spectrum.

  50. As a nurse practitioner I agree that doctors are the people with a medical degree and that their training leaves them better prepared
    Of course training and preparation costs and is becoming increasingly expensive.
    I would argue that training needs to change to address the accessibility of appropriately trained competent individuals who can treat patients be these doctors, nurses etc
    At present the elitism in access to medical school has excluded many able intelligent people from reaching their potential and we have a shortage of both nurses and doctors.
    Let’s work together to improve care and access for all instead of arguing about petty who does what best and come up with a solution to what is a very real problem. One day we will all need care let’s hope someone is there to deliver it

  51. You neglect to account for the clinical hours as a registered nurse. I have 10 years as an ICU nurse before I applied to my primary care program. And please remember in EVERY field there is a spectrum of excellence. I have met far more idiotic MDs who entered the profession solely for the prestige and could care less about the patient. There are exceptional practitioners and lackluster ones in ever field. Not to mention NPs must be rectified far more frequent than MDs, and for some specialties recertification is only recommended not mandatory.
    The decision to become an NP is not one entered into lightly and we ate fully aware of the differences. Hence we study day and night, join associations, subscribe to every EBR journal, and do everything to be as informed as possible. Not to mention consult with physicians.

  52. Amazing how these NP’s find these sites and just talk trash about physicians. If only they spent that time working with patients instead of pushing the propaganda and making these huge claims that doctors only care about the disease and not the patient. Every medical school teaches about treating the patient as a person. In fact, have you folks heard about OSTEOPATHIC MEDICINE? Their entire motto is treating the patient holistically.

    Let’s just straight to the point. The kids from my college and high school who went onto become nurses and nurse practitioners were C students and many of them were dumb as a rock. But now they flaunt their DNP degrees they got from Online Nurse Practitioner school where you can make up your own clinical hours and have them signed off.

    The fact of the matter is that NP’s want higher pay and more prestige for their online DNP degree.. That’s why they are pushing to be addressed Doctors and pushing against the term “mid level provider” as politically incorrect. They don’t care about welfare of the patients with independent practice.

    Oh and the “data” that says NP’s are superior? Yeah good work controlling glucose and blood pressure. How about you get the diagnosis correct and not spend excess $$$$ on tests as the data from the VA indicates…

  53. Regarding the rise of “doctorate” degrees… A world where everyone is a Doctor…..

    Dr. Saccoman (Ph.D, RN): Hello Patient, I’m Dr. Saccoman and i’ll just be adjusting your bed for you. let me know if you need anything
    Patient: Oh great nice to meet you Dr. Saccoman.
    Dr. Joyce (MD): Hi Patient, i’m Dr. Joyce and i’m here to ask you some quesitons
    Patient: Of course Dr. Joyce!
    Dr. Lee (Ed.D, MPH) : Hello patient, I’m Dr. Lee, and i’m here to counsel you on the social determinants of Health.
    Patient: Great Dr. Lee…
    Dr. Gold (Ph.D, Hospital Volunteer): Hi Patient, I’m Dr. Gold, Is there anything I can get you? Water, Blankets??
    Patient: I’ve seen 4 Doctors today who are taking care of me. Who the hell is my real doctor!!!

  54. I love the nurses coming on here and bashing physicians. First of there is no world where nursing school = medical school+residency+\- fellowship. None. Why not be truthful as to how one obtains a doctorate in nursing. Most are online. Several advertise little to no time on campus. Tests are honor systems. No classes really on medicine. Most classes on administration and other. What you’re “practicing” is nursing not medicine please stop telling the public you’re equal in care because you’re not. As far as positive “experience” with you NP, positive means nothing when you’re care has mishandled greatly. Or when a simple diagnosis is missed because of the lack of training. Want to practice medicine, go to medical school and stop saying you could’ve gone. The only thing that matters is patients health and they’re healthcare. That’s it.

  55. 1) Many physicians today working as PCP’s are trained in foreign medical schools with substantially lower standards than US based schools who then pass the boards here and practice primary medicine because it has the shortest residency and easiest placement rate.
    2) Their are bad, under prepared doctors just as their are bad under prepared NP’s. It is the patients responsibility to do their homework on who is treating them. ANYONE who makes wide over reaching claims that encompasses entire groups of people is probably unaware of how the system actually works, or works in the field and is insecure about their own quality of practice. What this article does not take into consideration is that NP’s must be nurses first. A Full time Nurse will work 1,800 hours a year in medicine and most reputable schools require 2 years of nursing experience prior to applying to the program in addition to the clinical rotation hours mentioned above.
    3) It is all about experience. I would rather see an NP who has practiced for 10 years than an MD or DO right our of residency. For anyone who believes MD’s are inherently better at their jobs than NP’s are probably falling right into societal stereotypes that view doctors as a profession that automatically receives respect rather than as a trades professional like any other Engineer, Lawyer, Scientist, or college professor.

    • Would agree except that it isn’t length of time that matter, but the quality of experience turning that time.

      Good Vanity Fair article piece regarding the Air France 447 crash and the differences in quality of experience between the two pilots.

      http://www.vanityfair.com/news/business/2014/10/air-france-flight-447-crash

      The crew arrived in Rio three days before the accident and stayed at the Sofitel hotel on Copacabana Beach. At Air France, the layover there was considered to be especially desirable. The junior co-pilot, Pierre-Cédric Bonin, 32, had brought along his wife for the trip, leaving their two young sons at home, and the captain, Marc Dubois, 58, was traveling with an off-duty flight attendant and opera singer. In the French manner, the accident report made no mention of Dubois’s private life, but that omission then required a finding that fatigue played no role, when the captain’s inattention clearly did. Dubois had come up the hard way, flying many kinds of airplanes before hiring on with Air Inter, a domestic airline subsequently absorbed by Air France; he was a veteran pilot, with nearly 11,000 flight hours, more than half of them as captain. But, it became known, he had gotten only one hour of sleep the previous night. Rather than resting, he had spent the day touring Rio with his companion.

      Flight 447 took off on schedule at 7:29 P.M. with 228 people aboard. The Airbus A330 is a docile twinjet airplane with an automated cockpit and a computer-based fly-by-wire control system that serves up an extraordinarily stable ride and, at the extremes, will intervene to keep pilots from exceeding aerodynamic and structural limits. Over the 15 years since the fleet’s introduction, in 1994, not a single A330 in line service had crashed. Up in the cockpit, Dubois occupied the left seat, the standard captain’s position. Though he was the Pilot in Command, and ultimately responsible for the flight, he was serving on this run as the Pilot Not Flying, handling communications, checklists, and backup duties. Occupying the right seat was the junior co-pilot, Bonin, whose turn it was to be the Pilot Flying—making the takeoff and landing, and managing the automation in cruising flight. Bonin was a type known as a Company Baby: he had been trained nearly from scratch by Air France and placed directly into Airbuses at a time when he had only a few hundred flight hours under his belt. By now he had accumulated 2,936 hours, but they were of low quality, and his experience was minimal, because almost all of his flight time was in fly-by-wire Airbuses running on autopilot.

  56. I came upon this article by accident but this guy seems he’ll bent on stereotyping without scientific evidence. Your article is simply regarded as personal opinion without such. As for my opinion about you, again just as validated as your assumptions, you see patients over an app. Wow, this seems very safe alot safer than an NP seeing a patient in person. You are also such a great doctor that you charge $15 for a consultation. No wonder you are blogging. I guess you have to make your money somewhere.

  57. This has been a rather amusing and occasionally informative thread.

    I would like to make an observation in regards to the assertion and argument of interchangeability. Often those opposed argue NPs providing comparable care are not “PHYSICIANS” as a litmus test of inferiority . NPs can and do provide many of the primary care and acute care services that Physicians do in the same setting . That does not make them equivalent in “title”, but quality is not dependent on the initials behind ones name. Just as a PCP may provide much of the same care to patients with heart disease , yet it does not make them a cardiologist. The question arises, does that mean they are inferior in managing hypertension?

    I would never equate the care I provide to my patients as being the same as a Physician, nor would I want it to be. I relish my training in relationship based care and focus on evidence based practice. But I will assert the quality of care provided within my scope has been proven repeatedly.
    Personally I find the ongoing attempts to compare and place NPs and MDs in some hierarchal war tiresome.

    To say “you don’t know what you don’t know” is most assuredly true and it goes BOTH ways. I would encourage those who dismiss the role NPs play in the growing healthcare environment take a moment to examine the numerous RCTs on outcomes, and patient satisfaction.

    This entire discussion has further secured my decision to go into speciality care. My team members and colleagues have embraced my position and approach. I have an “equally valuable” seat at the table alongside cardiologists, EPs and cardiovascular surgeons. Just as I consult and refer to them for a positive stress test or for worsening valvular disease they in return consult and refer to me for the ongoing management needs of their chronic cardiac disease patients.

    Team based disease management and care is the future of healthcare and those who refuse to be a team player will find it difficult. No longer do the initials behind ones name mean they are at the helm. “The leader is the team member with the greatest knowledge and experience and the best qualifications for the leadership task at hand. ” ACC

    And one last observation,
    NPs are not Physicians but they most certainly can be Doctors, as are most professors in Academia, as are some Pharmacists, as are Attorneys.
    Many of my fellow NPs have their DNP and some of us have a DNP and PhD, yet each time we enter an exam room we proudly introduce ourselves as a Nurse Practitioner.

    • “This entire discussion has further secured my decision to go into speciality care”. Precisely why this article is titled Why Nurse Practitioners Should Not Do Primary Care Without Physician Oversight. Good luck and thanks for your insights.

  58. I’m always very surprised by the MD who holds their self in such high esteem. The only reason an MD /DO has an advantage directly out of training is due to their monopoly on residencies. If they would allow doctors of nursing and other equally trained providers have residencies there would be a null difference in a first year NP/PA and a MD/DO. Passing the SMILE 1 doesn’t make you a better provider, expierence does. I really wish they would stop pretending it’s about the patient care and be honest, it’s all about the fear of loosing their cash flow.

    • It’s USMLE Step 1, 2, and 3 which are needed to be medically licensed, not SMILE 1. It’s experience (not expierence) and losing (not loosing). Not quite sure I agree with the use of “null” as opposed to “no” difference. As a MD, details matter!

  59. I agree that Nurse Practitioners need more clinical hours. I feel like the first year of FNP school was still talking about stupid nursing theory. I would rather start into shadowing and clinical experience for an entire extra year. I think the schools are doing Nurse Practitioners no favors. That being said I can’t agree with the article. I have had many physicians miss a diagnosis I have caught. I knew the answer from being a RN and not from school. Also, I have had many physicians diagnose me incorrectly and not listen to me. I think you can’t take generalizations and slap them into words. Let the statistics and patients tell you the truth. It seems sad to me that physicians often feel threatened by NPs. We work as a team and not 1 person MD, DO, NP, or PA knows everything.

  60. I should clarify what physicians missed. I had a MD with 5 years of practice say it can’t be a DVT if it is warm….”DVTs aren’t warm.” Also, I have had a different physician with 7 years in practice say it can’t be a cerebellum stroke because the patient has no N/V. They were wrong and in very serious cases with potentially scary outcomes. So while I respect the thought that you are concerned for the patients, I am hoping that is the essence of the article, I would heartily disagree with your assessment of ALL independent NPs.

  61. This is an interesting thread, and I see some very passionate responses. I think there is a traditional patriarchal understanding of what a nurse does and how much they know. Education in nursing is always evolving as is medical science. I have been a nurse for a long time, and also have seen awful conduct by physicians; however, that being said, I do think that they are essential to a multidisciplinary team. All our specialties are made to provide the best care in a team approach. One of the issues is that nurses are allowed to enter practice at various levels of education. This may be the crux of the problem that physicians have with us practicing primary care. They don’t know what educational level we have or how many years we have been practicing. If there was a uniform educational process with a minimal level of education such as a doctorate required before entry into practice, this likely wouldn’t be as much of an issue. As much as all of us would like all nurses to have a doctorate degree, its just not likely to happen while there is such a severe shortage of healthcare providers. That being said, a doctoral prepared nurse has had years of experience, and has likely had more time with patients than a physician coming off of residency. Do new physicians need oversight if they were to open their own practices? We should embrace each others capabilities, and not say that one is better at providing care than the other, because its not the truth. The Institute of Medicine and the Robert Wood Johnson Foundation advocate for nurse practitioners, and its too bad that there are some standing in the way in improving access and health outcomes by impeding NP progress.

  62. Physicians should call themselves physicians or MD’s.That is a protected title for them!!! Doctor is not,many other professions have doctorate degrees,which entitles them to be called DR. This can include nurse practitioners. Np’s have proven themselves in many many studies and over last 20 years. Physicians have more training and they are a precious commodity,however nurse practitioners are severely needed in medicine also and can handle the challenge. Physicians need to work with NP’s and stop demeaning them at every chance.Np’s should be independent in most situations. Physicians will always be needed ,especially in specialties,so I do not understand what they fear.

  63. First, I note the wide variation in egocentricity among the NPs commenting. I’m not a medical pro, but would think t hat humility and a good dose of self-doubt would be valuable attributes. This appears in two areas in the comments: first, among those either implying or claiming outright that they are fully equivalent to doctors, it follows that they are claiming that the very intense, highly selected, long, and arduous training of an MD has no value. If that is true, then why not allow RNs or CNAs to practice independently?

    Second, use of the title “Doctor” by DNPs is disturbing. Yes, if you are sitting in a university lecture hall, the prof would likely be addressed as “Dr. Smith.” Or, at an academic conference of NPs (I presume there are such things) it would be perfectly reasonable to address a presenter as “Dr. Jones.” Both those instances refer to a terminal degree, not a job title. In medicine, “doctor” has by long tradition come to have a specific meaning–someone who has endured med school, residency, and numerous examinations. Note that in Britain, completion of medical school confers a suite of bachelors degrees but those graduates are referred to as “doctor” in clinical settings. (There, the MD is a research degree, equivalent to the MD/PhD in the US).

    Yes, if I go in for a physical and an NP introduces him/herself as “Doctor,” I can likely tell from a name tag or further intro, but if I’m really sick or in pain that might not register. In either case I would run screaming from the office because that person is simply trying to imply a level of training they simply don’t have. Big egos are dangerous.

    The second area I note relates to claims of equivalency in training. This is problematic. First, selection–if you don’t have almost straight A’s in undergrad, taking some very serious math and science courses, you won’t get into med school in the first place. Yes, I know that a lot of NPs are plenty smart, but getting into a nursing program is not even close in competitiveness, and much of the coursework is far less rigorous (compare typical requirements for organic chem and biochem, for example.)

    Some have argued that many NPs had a lot of nursing experience prior to getting NP certs, but as the OP points out, that just doesn’t compare in rigor to med school rotations and certainly not to residency (and I note that the 3year residency is 3 years of 60-80 hour weeks, equivalent to somethIng like 5-6 actual human working years So, even for seemingly routine issues, there is a much higher probability that a doc would spot atypical presentations or uncommon diseases.

    Now, I’m not dissing on NPs or PAs here. They are absolutely necessary, and in very small communities independent practice may be the only option to provide any health care at all. I sometimes see NPs or PAs myself, and haven’t any horror stories to pass along, but those few I’ve seen aren’t the giant ego sorts. I’ve only been to one solo NP (for a vaccine for tropical travel), and it took some arguing and bringing in a CDC printout of protocol to get it right, but it’s not an everyday vaccine, so taxed the NPss knowledge base, which is not an end-of-world issue. Also, I note that after the first confusion and presentation of evidence, she admitted her error and apologized–a big ego sort might well have argued right to the wall, and that is not acceptable.

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