Sunday, February 13, 2011

Dcotors and Nurse Practitioners

There is a vigorous discussion in medical care organization policy circles on the role of physicians, and the role of “advanced practice nurses” and physician assistants. How much can the role of the doctor be played by these so-called midlevel practitioners? In practices headed by physicians, midlevels already thrive. But the recent ACA legislation has succumbed to the nursing lobby and granted money for independent nurse practitioner clinics where physicians would not be present.

I present here a discussion from our American Academy of Pediatrics administrative listserve that I found interesting. You can’t make these arguments persuasively without looking closely at what actually happens, and what people in the field find. In this listserve exchange we hear first from Seth Kaplan, pediatrician in Texas, on his day where he had to exercise a great deal of his physician prowess. What would a nurse practitioner have done with these patients? Jon Caine of Massachusetts answers puckishly. Finally, David Horowitz of North Carolina makes the case (which I have shortened) that some docs couldn’t have handled this case load as well as Seth did, but that some nurse practitioners could have given it a pretty good shot. David points out, rightly, that a person is not totally defined by his or her training.

First, Seth:

There's been a lot of talk on the listserv about the possibility of mid-level providers replacing general pediatricians over time. I'm sure most of you have had similar days, but this is a synopsis of my day today:

The normal well checks and sick checks, dominated by gastro and a febrile illness without much of a source, with fevers to 103-104 lasting 4 to 6 days.

A 4 month well check with a very depressed mom.

A new sick patient with fever, who, oh by the way, has adrenal insufficiency, growth hormone deficiency, thyroid dysfunction, and some unidentified underlying disorder.

One of the kids with high fever for several days who had some small lymph nodes and mom has been convinced he must have cancer and will no leave without getting a cbc done and the cbc has an ANC of 700 (probable viral suppression - kid otherwise looks good, but we will be rechecking counts).

An 11 year old with poorly controlled asthma due to parental non-compliance and poor understanding who I ended up having to admit.

A well 7 year old with the "oh, by the way, I'm concerned about inattentive ADD".

A teen brought in for concerns about weight loss, "not looking well for 3 months, does he have diabetes?"

A child with arthyrogryposis with growth patterns that are difficult to make heads or tails of.

The sick kid with gastro amongst many who only came in because they wanted Zofran, but their exam sure seemed a lot more like appendicitis and it took 20 minutes to convince the mom that we really did need to image, check labs and get a surgical consult despite the fact in would involve a needle stick and maybe an IV, because "if she doesn't have appendicitis, I don't want her unnecessarily stuck"

The new well visit with an adopted kid who is a victim of sexual abuse both by her birth parents and multiple foster families, who exhibits signs of PTSD and major behavioral problems.

One of the kids with the high fever thing whose mom took him to Minute Clinic after school 3 days ago because "it was right next door" and the NP told them that "she was going to stop taking the temperature because it went up every time they took it and if it is above 103, we have to refer him out."

All of this in ONE DAY. Would love to see a "mid-level provider" handle it all.

Don't really have a question, just venting and thinking that we do is awfully challenging. We should be proud to be general pediatricians and continue to fight for our role in the healthcare system.

Seth D. Kaplan, MD, FAAP
Frisco, TX

Now, Jon’s reflection on Seth’s day (note the increased costs the nurse practitioner’s actions would entail):

No one is saying that PNPs will be effective or even cost-effective replacements for pediatricians. But, as long as Scope of Practice laws continue to be passed allowing independent practice in states where the politicians "think" they will save money, it will continue to progress. How would a PNP in independent practice handle your day?

1. Normal well/sick visits - Piece of cake
2. Depressed Mom - Refer to psych
3. Multiple Endo Pt - Refer to Endo
4. Neutropenia - Turf to Tertiary Children's Hospital ED for workup
5. Asthma Exacerbation - Turf to Local Hospitalist or Children's Tertiary
6. ?ADD - Refer to Pedi Neuro - 4-6 month waiting list
7. Teen with weight loss - Back to Children's Hospital ED
8. Arthrogryposis - Refer to Genetics & Endo
9. R/O Appendicitis - Give Zofran. "If pain worsens go to ED".
10. PTSD - "Call your insurance plan for psychiatrist who is participating in their closed panel".
11. Minute Clinic kid with fever and shockingly no antibiotics - Rx: Antibiotics
12. Lunch Break

Jon Caine MD

Tongue somewhat firmly in cheek.

A quick note from Jeff Couchman of Arizona:
Actually, I think many of the people who are changing scope of practice laws actually ARE saying the PNPs will be effective and cost-effective replacements for pediatricians…
Jeff Couchman, MD
And finally, from David Horowitz (edited):

I have worked with a PNP who could handle all (all right, most) of those kids appropriately. I have worked with real board certified pediatricians who would have handled this list the same way listed (by Jon), or even worse, attempted to treat the complicated kids and do it wrong. IMHO, one of the key attributes of being a good doctor or provider of health care is to know what you don’t know but know where to find the answer to those questions you don’t know. The bad docs I’ve worked with didn’t know that they were doing the wrong thing for their patients. All of the NPs I have hired have freely come to me with questions when they didn’t know the answers and asked very appropriate questions. That is because the structure I provided in my office meant that the NP was never there alone.

The question of the role of NPs is a lot more complicated than “should they replace us”. The first PNP I hired was one of the smartest people I’ve ever met. She was competent enough to work sick call on evening hours by herself and I never felt uncomfortable because I new she would call me if there were issues. She did more work in the running of the office than many hired doctors I have had. On the other hand, I have had an FNP work in my office who I felt I had to look at every ear to confirm if it was a real otitis or not.

…(It is important to note that) not all NPs are created equal and there are several training tracks: Pediatric, Adult, Family, and Neonatal. …There is no doubt in my mind that the ONLY qualified NPs to do any serious pediatric work are PNPs. Adult NPs have no training in kids at all, and FNPs are similar to Family Practice doctors in their training, and I see little to no role for them in seeing quantities of children.

(But) as good as some PNPs are, they are not doctor replacements, they are doctor extenders. While the laws may be structured so that the doctor doesn’t have to be physically present in the building to provide supervision (I am thinking of rural health centers here, not Minute Clinics), there MUST be a supervising pediatrician immediately available by phone. I am against totally independent practice without any MD supervision and this aspect is one area to focus our attention on legislation. I can also see different rules for rural health clinics where there is a lack of other qualified pediatrician services as defined by the government, and Minute Clinics, which are totally different in purpose and orientation.

David Horowitz

Tuesday, February 8, 2011

My Son Peter - A Reminiscence

When Peter was small, he was really small. He was born small at 35 weeks gestation when Ann had HELPP Syndrome, which had yet to be described in the literature, so as her blood didn’t clot and her BP was up and her liver enzymes were up and she was very sick and went into labor at 35 weeks, we all weren’t sure what was happening. It turned out all right and Peter more than survived. But he was small. Today he is just a bit shorter than I am and all muscle and very athletic, but when he was younger he was small.

But smart and with an emotional IQ of 150 from the day he was born. Here he would be, about three feet tall, standing by the door and looking straight up at our friends and say, “How was your vacation?” People would say, is that a little kid, or is that a midget? And they would leave saying, “That kid is going to be President.”

But before that, Pete was small and very verbal as a three year old. Having older sibs was a big help because he acculturated readily, and made the expressions of others his own. He taught himself to read by taking baseball cards and finding out where they belonged in the scrap-book by comparing letters in the names. He had no hesitation in parroting. One day he turned over the telephone (let’s all date ourselves), saw the symbol and said, “AT&T – The Right Choice!” Big mouth, my parents would say.

So Ann had passed the bar, worked for a firm she didn’t particularly like, then went to work for a small firm she did like, and we invited the youngest partner and his wife over for dinner, and some lawyer patients of mine that I liked, and we had dinner. It was a nice time, and we were on our good behavior, as one would be in that circumstance. A nice dinner and nice talk as Ann and I tried to find ourselves in our new lives as young professionals.

As the dinner came to an end, who would provide the coup de grace? Peter, of course. So down the stairs he came, our little verbal cherub, as the dinner broke up and we all headed for the door. “Here’s Peter!” we exclaimed, and started to introduce him.

Pete walked down the stairs and surveyed the situation with his 150 emotional IQ. We were so proud, he was so darling. Then he spied in our front hall – we had five kids, after all – a parked bicycle. Well, that happens. But Pete was no doubt conscious of how this violated the image of the young lawyers. His visage clouded over, he became incensed, he approached the bike head on, he glared, he kicked the front tire, and with the impassioned heat of a violated host pronounced: “I told Brian to keep his fucking bike out of the hallway!”

I’m still laughing at Peter – and, I guess, at our little pretensions. I guess I could have sent it in to Reader’s Digest if it were a little less of a family magazine.

Budd Shenkin