Haters gonna hate

6Jan - by Sandy and Harry Summers - 0 - In NEWS

Op-eds on NPs reflect the physician gaze

Ezekiel EmanuelJanuary 6, 2015 – Over the last year, several op-eds have conveyed critical views of advanced practice nurses (APRNs) and how they fit into U.S. health reform efforts. On December 4, 2013, the New York Times ran an op-ed by physicians Scott Gottlieb and Ezekiel J. Emanuel arguing that the predicted shortage of physicians was unlikely to hinder Obamacare, in part because of the abilities of nurse practitioners (NPs) and others. The piece made several good points about the value of teamwork and the need to expand the scope of NP practice, although it was marred by the sense that nurses were merely assisting physicians with “routine” matters or “expanding” their care, rather than practicing under the nurses’ own autonomous model of care. On April 29, 2014, the Times published physician Sandeep Jauhar’s “Nurses Are Not Doctors,” which argued that New York State’s recent move to join the many states that permit NPs to “provide primary care without physician oversight” was a big mistake because, in essence, NPs supposedly cannot provide high-quality, cost-effective primary care on their own. The piece amounts to little more than its headline, as it relies mainly on anecdotes, unsupported opinions, and one ambiguous 1999 study suggesting patients of NPs got more follow-up care, while ignoring the vast body of research showing NP care is at least as effective as physician care. Today, an even more direct attack appeared in the New York Post. Betsy McCaughey’s “When a nurse is your health-care provider, you’re at risk” also argues strongly against the New York law. McCaughey contends that nurses should not be allowed to “play doctor without going to medical school,” even though they are good at patient education and some “routine” things, because they are less able to diagnose uncommon conditions. McCaughey is not a physician, but she relies on physician opinions and the length of physician training. Evidently the research “purporting” to show the quality of NP care is all biased or unscientific. And there is a priceless anecdote from a physician who says he once diagnosed an unexpected condition and speculates that an NP “would’ve” missed it. Now that’s science! We could just shake it off, but it’s our job to note that these views, whether motivated by competitive concerns or professional bias, seem like desperate efforts to stave off the inevitable with insults, unsupported opinion, and distortions of the relevant data.

Expanding the reach

“Nurses are not doctors”? You say that like it’s a bad thing

Playing doctor

Expanding the reach

Expanding physicians' reachScott Gottlieb and Ezekiel Emanuel are both veteran policymakers—Emanuel played a key role in the creation of Obamacare—and in their piece, “No, There Won’t Be a Doctor Shortage,” they argue that alarms raised by physician groups about access to care are unjustified. The authors acknowledge that more people will soon need care because of the expansion of coverage under the Affordable Care Act (ACA) and the aging of the U.S. population. But they note that Massachusetts has not seen a significant increase in wait times since its introduction of “Obamacare-style reforms” in 2006; that more older patients can now be treated in “subacute settings” rather than hospitals; that various new technologies have reduced the demand for physician time and should continue to do so; and that “other medical personnel can also expand the reach of physicians to care for a larger population.” In addition to NPs, pharmacists, and other providers, the authors note that “nurses will provide wound care to diabetic patients, adjust medications like blood thinners and provide the initial management of chemotherapy side effects for cancer patients.” Of course, “physicians will remain essential to the proper diagnosis and treatment of disease, but [they] will be backed up by teams who will help manage the more routine features of chronic illness.” The authors call for “expanding the scope of practice laws for nurse practitioners and pharmacists to allow them to provide comprehensive primary care,” and “most important, we need to change medical school curriculum to provide training in team care to take full advantage of the capabilities of nonphysicians in caring for patients.”

Scott GottliebThat last idea sounds excellent, as does the call for expanding scope of practice laws and the overall message that physicians must recognize they are part of a large, diverse “team” now and cannot expect to control the whole show. The reference to what “nurses” will do in caring for diabetic patients and others is also somewhat helpful, although nurses already do those things to a significant extent—and in fact are more expert at much of it than physicians are. So the implication that these are new things nurses will need to learn, perhaps from physicians, is not helpful. And unfortunately, other elements reveal a condescending view that physicians remain the lead in health care and everyone else is just backing them up by handling “routine” matters. In fact, NPs are not “expand[ing] the reach of physicians,” but providing high-quality care to patients under their own independent holistic practice model. And they are fully capable of handling more than “routine” matters, as they have been for years.

“Nurses are not doctors”? You say that like it’s a bad thing

Sandeep Jauhar’s Times op-ed is headlined “Nurses are not doctors.” The author, a cardiologist, objects to a new New York state law that will permit NPs to provide primary care “without physician oversight.” Jauhar acknowledges the views of the Institute of Medicine that such practice barriers should be dropped and of the American Association of Nurse Practitioners’ president that such “hierarchical, physician-centric structures [are] unnecessary.” Jauhar responds to that last quote immediately with “as a physician, I couldn’t disagree more,” thus endorsing “hierarchical, physician-centric structures.” He argues that “such proposals underestimate the clinical importance of physicians’ expertise and overestimate the cost-effectiveness of nurse practitioners.” Jauhar says the law is the result of “the dire shortage of primary-care physicians,” which he attributes to their relatively low pay, just when the ACA is increasing the need for primary care. NPs have been promoted as a cost-effective way to meet the need, he notes, with Medicare reimbursing them at only 85% of what it pays primary care physicians. But Jauhar questions that view, arguing that although there is “a dearth of good recent empirical research” on it, “some studies have suggested that the answer is no.” Specifically, he says that NPs seem to prescribe more follow-up care, relying solely on a 1999 study in the journal Effective Clinical Practice in which “primary-care patients assigned to nurse practitioners underwent more ultrasounds, CT scans and M.R.I. scans” and “had 25 percent more specialty visits and 41 percent more hospital admissions.” He quotes the study as saying that these differences “may offset or negate any cost savings achieved by hiring nurse practitioners in place of physicians.” Jauhar admits that there may be “many reasons” for the differences, but “it seems most plausible that [the nurses acted] to compensate for a lack of training.” Jauhar also argues that NPs get about 600 hours of clinical education during their formal education, which is less than physicians get in their first year of medical residency. Jauhar argues that although primary care does often focus on “relatively straightforward illness prevention and health promotion, there will always be subtleties and complexities that demand a doctor’s judgment,” noting how much primary care practitioners must know to make difficult diagnostic judgments. Therefore, although there is “an essential place for nurse practitioners in medicine, … it is as part of a physician-led team.”

We see some problems with this piece. It refers to “studies,” but specifically cites only one, a 15-year-old study that found patients seen by NPs–nine NPs–had more follow-up activity. However, Jauhar fails to mention that the researchers were not even sure if the NPs asked for the tests or if they were prescribed by specialists who saw the patients later. They could do no more than speculate about what the study might mean, noting that increased follow up tests “may” offset cost savings, though the study did not examine that nor how the patient outcomes compared. Nor does Jauhar mention that the study did not examine if NPs diagnosed more real problems, by taking the time and listening to patients, and saved funds that way. In any case, diagnostic practice is not the only measure of cost-effectiveness or quality, and it seems quite possible that the NPs saved money by managing chronic conditions and promoting wellness better. Jauhar, like Dr. House, doesn’t seem to understand the importance of those activities, in which NPs excel. Research done more recently finds that NPs are more cost-effective. Jauhar managed to find one study in which there was an extremely weak suggestion that NP care was worse MD care. But he ignores the massive body of research, spanning many decades, showing that the care of APRNs is at least as good as that of physicians. Indeed, that is why APRNs should be compensated at the same rates as the physician practitioners. And suggesting that APRNs overuse expensive interventions is ironic, since in many contexts they plainly do far less of that, for instance in avoiding risky, unnecessary C-sections. Jauhar also distorts the training comparison, counting physician residencies but appearing to discount NP residencies as well as the informal training NPs get in their first years of practice and that many get in prior RN practice. What Jauhar has is not evidence, but biases and speculation, which he seems happy to rely on even in the face of contrary data.

Playing doctor

Betsy McCaughey’s New York Post op-ed is headlined: “When a nurse is your health-care provider, you’re at risk.” The author is “a senior fellow at the London Center for Policy Research.” McCaughey says New York has become “the 19th state to capitulate to aggressive lobbying by nursing groups to let some nurses play doctor without going to medical school.” She assures readers that nurses are “the backbone of the health-care system, and generally they’re better than doctors at educating patients and providing many types of routine care.” But she argues that their training does not prepare them to do everything physicians do, “especially diagnosing less common conditions.” She says that NP training generally consists of “six years beyond high school, instead of [the] 12” physicians get. And she relies on Jauhar’s piece. McCaughey also claims that a “2013 analysis in the New England Journal of Medicine shows why physicians oppose the change, and it isn’t to keep business for themselves.” But she doesn’t explain what that analysis actually says. She does state that “with the physician shortage, [competition] is not an issue.” McCaughey argues that NPs gets less education in how the body works and are “trained to treat symptoms.” She spoke with “one doctor” who told her about a patient with “apparent signs of adult-onset diabetes. A nurse practitioner, he said, would’ve prescribed medicine to produce insulin.” But the physician connected the symptoms with a recent gallstone attack and realized that the real problem was that a gallstone was in her pancreatic duct. McCaughey says that “detective work” is “what is taught in medical schools.” In addition, “Dr. Jane Fitch, president of the American Society of Anesthesiologists,” once a nurse anesthetist, now says that as a nurse “I didn’t know what I didn’t know.” McCaughey says nursing groups “suffer from that over-confidence.” And “most” of the studies on which they rely, which “purport… to show that patients do as well with a nurse practitioner as with a primary-care doctor[,] are sponsored by nursing outfits or lack scientific rigor.” She criticizes the prominent study led by Mary Mundinger as lasting only six months and involving only one provider visit for most patients, and she says that a Journal of the American Medical Association “editorial” found it “far from convincing.” McCaughey concludes by praising the December 2014 federal budget deal for delaying the Veterans Administration “plan to substitute nurse practitioners for primary-care doctors until the risks could be assessed.”

Perhaps the most striking problem with McCaughey’s piece is her focus on diagnosing unusual conditions. That is not because she overstates the importance of that diagnostic task (which is also a common theme of physicians who oppose NP autonomy), but because her support is so weak. It seems to consist of the false claim that NPs are trained only to treat symptoms and an anecdote from a physician who claims to have diagnosed a condition that an NP “would’ve” missed. Really? Would an NP have missed it because he was too busy rushing off to his next 5-minute appointment to really listen to the patient? One reason there is no actual scientific support for the claim that NPs can’t diagnose well is that their preventive, holistic model of care makes up for any perceived educational disparity. And speaking of education, McCaughey’s 6/12-year claim is at best a distortion, since the most relevant comparison is years of formal health care education, which for NPs consists of 4-6 years before they even become NPs, depending on whether they get the four-year DNP that will soon be the standard entry degree. For physicians, it is the 4 years of medical school–an amount that is less than or equal to NP health education. backboneMcCaughey, like physician advocates, then counts the physician residency as education but not NP residencies, the early years of NP practice, or the years of prior clinical practice as RNs that many NPs have. McCaughey also claims that physicians who oppose NPs are not motivated by competitive concerns because of the supposed primary physician shortage. The Gottlieb/Emanuel op-ed suggests that shortage is illusory. We also note that internal medicine physicians tend to earn most in U.S. states that place the greatest restrictions on nursing practice. But anyway, we would concede that in some cases physician opposition is due simply to unfounded professional bias. McCaughey at least waves at the decades of research showing that APRN care is at least as good as physician care. But here again, her criticism is weak. It consists mainly of faulting the Mundinger study for being limited in time and quoting a JAMA op-ed; she neglects to note that the study was itself published in JAMA and that its findings have been confirmed in many other studies, as meta-analyses have shown. Finally, McCaughey acknowledges that nurses are better at some things. The “educating patients” part almost sounds like it matters, although evidently it doesn’t matter in primary care, since patient knowledge and behavior must not have any effect on patient wellbeing! As for nurses being the “backbone,” that’s a good angel-oriented compliment. But backbones don’t really do any thinking, do they?

See the New York Times op-eds, “No, There Won’t Be a Doctor Shortage,” by Scott Gottlieb and Ezekiel J. Emanuel, posted on December 4, 2013, and “Nurses Are Not Doctors,” by Sandeep Jauhar, posted on April 29, 2014.

See the op-ed “When a nurse is your health-care provider, you’re at risk,” by Betsy McCaughey, posted on January 6, 2015 on the New York Post website.

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