The Widdershins

Remain Calm, Etc: The Unreasonable Facsimiles

Posted on: June 5, 2014

Good Thursday, Widdershins.   I am packing madly to leave tomorrow.  The bungalow is being fumigated for termites, so all consumables must be taken away, the canines are off to be boarded, my aging feline will spend the weekend with my daughter, and the BFF and I are off to a convention.  It should not be legal to have this much fun in one short week.

I decided to open up an rarely used mailbox, and came upon an article forwarded by an old colleague.  The article is written by a physician, and concerns the proposed changes to practice standards for ARNP (Advanced Registered Nurse Practitioners) which would permit the nurse to practice without a supervising physician  The doc is not happy with this, and wishes for us all to know exactly why he feels that way – a nurse is not a doctor.  Further, ARNPs are insufficietly educated, and appear to be turning patient care into a two-tiered system.

Well, duh, Doc.  You don’t say.  Nor do we claim  to be, or even wish to be physicians.   Women go to med school with impunity these days – we no longer “settle” for nursing.  The author claims to have had some nurses in his medical school class – you know, the really bright ones who know enough to go to med school, and that may well be.  In the 44 years since I graduated from nursing school, I have personally known a whopping 3 RNs who did so. For the most part, those who wanted that style of practice became an ARNP, and deserve appreciation for what they contribute to the system.  They are not a “doc lite”.  They are not faux physicians.  They are practitioners in their own right.

All of this has become noteworthy because of the recent desire to place more primary care duties into the hands of ARNPs.  With the relative dearth of primary care physicians and the anticipated uptick in demand for services engendered by the AHA, you will likely hear even more about this in the forthcoming days.  There has been an increase in the ARNP ranks, they are reimbursed by both Medicare and private insurances at roughly 85% the rate afforded to physicians, and they are performing jobs that most physicians don’t especially want because these jobs have higher volume and lower rates of compensation than the more desirable specialties.

The article cites a 1999 study which concluded that ARNPs order more tests and are therefore less cost-effective than physicians would be.  Seriously?  I don’t know what to say about that other than that the study is fifteen years old.  1999 likely had fewer and less experienced ARNPs than today’s group might be.  I also know that Minute Clinics and other Urgent Care Centers have been manned by nurse practitioners for years.  They treat what they can, and refer the rest to an Emergency Room, much like your family physician would do.  There is no supervising physician on the premises – one friend who is employed by a chain Urgent Care Center tells me that her supervising doc is in Jacksonville.  On the whole, the concept appears to be working.  As far as education goes, an ARNP has a BS in Nursing, a two year MS plus additional education that enables her to pass boards.  The ARNP then serves a preceptorship of varying length.  So where did this highly objectionable 600 hour educational figure come from?  You have to at least count some things from nursing school.  Terminology does not change, nor does basic physical assessment. The more detailed assasment and treatment is then taught over 2-3 academic years.  Most ARNPs study primary care, but others choose pediatrics, gynecology, infectious disease, public health, or correctional facilities.   Because they do not rotate through every service as in medical school, the ones that I have met are quite proficient at what they do, and know enough to admit what they do not know.

His next concern is that the use of ARNPs will create a two-tiered system of care.  He may well be correct, but I submit that a two-tiered system will be a giant leap forward from the myriad of tiers that are currently in play.  The bottom tier is ER only, then we inch up to free clinics, people with some kind of insurance who can get private care, people with good insurance,great insurance, top-notch insurance, and people with so much money that they can afford the best.  How many tiers would that be?  Just imagine the differences in outcomes…….

Medicine is under the spotlight.  Medical costs are cringeworthy, as are many medical outcomes.  This is the wrong time to start a fight in the house, Doc.  Just sayin’.

This is an open thread.



14 Responses to "Remain Calm, Etc: The Unreasonable Facsimiles"

When I have gone into the BCBS website under the find a physician portion I’ve seen a few NPs listed. In addition, looking through the plan brochures I saw that when listing payments for primary care doc visits, the reimbursement rate is indeed lower for NP’s than for the docs.

Physicians do not want to practice primary care. A fellowship of maybe two years length would double or triple their salaries.

@2: That’s a shame because there is a need for them, but if NP’s can fill the bill, why not? I would be just as comfortable with them.


I’ll be posting tomorrow for Friday and the weekend, I’m going to make it a Weekend Light Fare post.

2nd: Has anyone had any experience with Internet Explorer 11? My Windows updates keeps bothering me about installing it and I can’t make the notice go away.

Not a clue. Sorry.

Okay, thanks chat. Maybe someone else will have some experience with it.

Whoa, Vlad. The women of Russia may not be too happy with that one, either,

DYB@7: Just saw that on the news. Incredible.

The Russian media may not even report his comments. Most of the media is very much controlled by the state and the level of propaganda is enormous. Imagine having access to nothing but Fox News. Now imagine there are about 20 Fox News outlets.

It’s a little different in large cities. There is still *some* independent media there (mostly press), but they are constantly harassed. And much of the general public, much like so much of the US public, prefers to believe what they hear from “Fox.”

@10: A skulk of Foxes? Have mercy.

DYB@10: Geez, just like the old days eh?

Chat, very interesting post. I am all for NPs. I think a lot of them are better care providers than many doctors. I hope you have a fun week!

I saw what Vlad said about Hillary. I seriously think he is an evil person, and a misogynist of the first degree.

Fredster, look forward to your fun posts!

I’m off for the weekend. See y’all Monday.

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