Friday, May 29, 2009

Do internists have confidence in their own training when compared to NPs?

Last week, ACP President Joseph W. Stubbs, MD, FACP, joined with other
primary care physician and nursing organizations to endorse the Preserving Patient Access to Primary Care Act, H.R. 2350, introduce by Rep. Allyson Schwartz (D-PA).

H.R. 2350 now has more than 100 co-sponsors in the House of Representatives, and Senator Maria Cantwell (D-WA) plans to introduce a companion bill in the Senate. In a press release issued yesterday to announce her plans, Senator Cantwell quotes ACP: "According to a report issued by the American College of Physicians, 'primary care, the backbone of the nation's health care system, is at grave risk of collapse.'"

Unlike other bills that address the primary care crisis in a piecemeal fashion, the Preserving Patient Access to Primary Care Act addresses the issue in a comprehensive way. It will fund more primary care training programs through the National Health Service Corps and Title VII primary care programs, provide scholarships and loan repayment for primary care physicians and other primary care professionals in critical shortage facilities or geographic areas, break down regulatory barriers to training medical students and resident in primary care clinics; increase primary care Graduate Medical Education slots; raise Medicare payments for primary care; pay primary care physicians for care coordination; allow savings in Medicare Part A associated with primary care to be put back into primary care; and give primary care practices the option of receiving additional care coordination payments for becoming Patient Centered Medical Homes (PCMHs).

Yet, despite all of what the bill does for primary care physicians, its treatment of advance practice nurse is a sticking point for some. It would allow NP-led practices to qualify as Medicare PCMHs, within the limits of their state licenses and if they meet the same standards as physician-led practices.

ACP policy recognizes the important contributions nurse practitioners make to primary care but makes the case that the training and skills of each profession are complimentary, not equivalent. In the PCMH model, "care for patients is best served by a multidisciplinary team where the clinical team is led by a physician" says ACP, but "given the call for testing different models of the PCMH, ACP believes that PCMH demonstration projects that include evaluation of physician-led PCMHs could also test the effectiveness of nurse practitioner-led PCMH practices in accord with existing state practice acts and consistent [with meeting the same eligibility and qualification standards as physician-led practices]."

H.R. 2350 goes beyond ACP policy, in that it would allow NP-led practices to qualify as PCMHs, not just for demonstration projects as proposed by ACP, but under a permanent Medicare PCMH benefit, starting in 2011. ACP's top physician leadership made the judgment that H.R. 2350 merits the College's strong endorsement, even with the more expansive NP language, since perhaps 95 percent of the bill is based on ACP policy.

In the days since ACP endorsed the bill, some ACP members have expressed concern that ACP's support will further blur the lines between general internal medicine and advanced practice nursing, making it even harder to persuade young people to go through the extra years of training to become a physician But if internists truly believe in the value of their training, shouldn't they also be confident that they will be able to show such value in a medical home model where the outcomes of care can be measured?

My bet is that the PCMH will help support the value of internal medicine training by providing a consistent way to measure the outcomes, effectiveness and efficiency of care provided by internists, even when compared to nursing-led PCMHs that operate within the limits of their licenses and against the same evaluation benchmarks. And, as I've written about before, our chances of getting primary care legislation could be irreparably weakened if physicians and nurses are viewed as being in competition with each other, rather than as allies on the need for more of both.

Today's question: Do you believe that internists will be able to demonstrate the value of internal medicine training, even when compared to NP-led medical homes using the same evaluation benchmarks?


Jay Larson MD said...

General internal medicine is one of the most cognitively challenging fields of medicine. We take care of those who don’t fit guidelines due to their complexity. There is much more than “evaluation benchmarks” to the art of medicine. At the end of the day what really matters is that patients are care for, counseled, and treated appropriately. This can only be accomplished with dedication, education, and training.

Steve Lucas said...

My perception and reality as a patient is no. Today many doctors see 50 patients a day and do not even attempt eye contact, instead focusing on the file in front of them, and the potential for more test. Many times the only physical contact a patient has with a medical person is with the nurse.

Another reality is many doctors will state on a first visit any after hours or medical emergencies should be directed to the nearest ER.

While I am aware of the financial needs of a medical practice, patient interaction will sway this decision. I also believe doctors are better at diagnosis, but the simple reality is the bulk of our needed medical care is for a short list of problems. Here again many doctors boot the problem to an ER for a solution and then design a course of treatment after they have been essentially told what the medical problem is.

Doctors need to reestablish their role in the care of patients or they will be further marginalized, and we would all suffer under this model.

Steve Lucas

PCP said...

This is a false comparison, and herein lies the problem. We all understand that for a majority of patients NP delivered care would be adequate, not all however. Where does the Advanced medical home lead us? Billing codes have never adjusted appropriately for severity levels. The evidence of this lies in the "success" of the patient mill model of patient care. NP run advances medical homes will compete for the simple cases and leave generalists with the train wreck cases, for pittance pay.
Nurse Practitioners should be working in collaborative relationships with Doctors within Advanced medical homes. Their goal however has never been to collaborate with us, that is what they say so as to make their demands politically acceptable, their ultimate goal is to legislate their way into peership and so we eventually leave and create a void which they will fill awkwardly and insufficiently.
The ACP has taken a very short sighted stand on this issue. The current scenario where the income discrepancy between NP and General Internist pales into comparison with that between Generalist and Specialist tells the sad tale. Now the ACP says that a foodfight with the nursing lobby will fracture the primary care so we should accept peership. I've never heard a more ridiculous reason for supporting something. It is almost as if we are afraid to ask for what we rightfully deserve. We all know primary care needs fixing, if that fixing means filling the current primary care void with APNs, we are about to accomplish this in a big way. Internists would have handed to the Gov't the noose with which our profession will be hanged(or should I say slowly strangled). We will be left to go into concierge practices, Directorship roles, and other non clinical leadership positions. Hospitalist practices will continue to grow and absorb all the general internists, the acuity and severity of care in the hospital setting will keep our services more in demand there, there will continue to develop a huge chasm between IP and OP care, and coordination will suffer and patients will come to learn that they see doctors only when they are wealthy or extremely sick, otherwise they see nurses. This is just plain stupid.
The ACP has blown this thing entirely. They are out of touch with the younger generation of Generalists. They failed to see that a General Internist wants to be their patients doctor and lead a team including NPs/PAs/CDEs/RNs etc. but the system as currently structured did not allow it, simply put, we feel each patient deserves to have a doctor of record responsible for his/her care overseeing the team, NOT A NURSE PRACTITIONER OF RECORD. This is the minimum standard the ACP ought to have pushed for. The ANPs will now just bypass the generalist and set up referral relationships with enthusiastic specialists for anything but the most routine cases. Where exactly does that put our profession in 25 yrs? Mid-level provider autonomy has been part of the problem, and noone wants to say that. It cannot then be part of the solution.
When payers make no differentiation between the professions in terms of their treatment of Advanced medical homes, then where is the incentive for Generalists to choose OP Internal medicine? Where is it that my education/training/skill level is rewarded? What exactly differentiates me from a NP in the Public's eye? How many of our population are sophisticated enough to know or even realize our differences once we are in labcoats? Some are, but are they 30% perhaps? I've worked in CHCs with APNs, they mean well and they have a large role to play in solving this primary care mess, however when they try to do it without physician leadership, it is not be a pretty sight. There will be a void as no younger doctor is going to accept this deal. Apparently that is one road we have to walk along as a nation to come up with sensible team based care. The ACP appears hell bent on advocating for the CHC model of health care delivery for all. I simply want to be my patients independent doctor.

PCP said...

Younger Internists are more shrewd than their leadership, and are voting with their feet. That sadly will not change with these developments.I find it comical that the ACP found it a surprise that the 5% that went into the bill was peership for ANPs in the Advanced medical home model. They only proposed to 'study it' in their paper on APNs in primary care.
They left the door open, and the NP lobby walked through it?
I can't say I'm surprised.

Arvind said...

Dear Bob:

This dilemma you are expressing is what organisations like the ACP should have understood long ago. When physician organisations start endorsing political viewpoints and supporting government intervention is health care, the 5% will overshadow the 95% - if you get the drift...

It has long been the proclamation of physician-unfreindly Democrats that NPs can pretty much perform all the functions of general Internists and FPs; and proliferation of NP-based primary care is the only sure way of reducing costs.

Just look what ODs did to the practice ophthalmology! In a few years, the ACP will be forced to admit that its "efforts" in 2009 contributed to demise of primary care as practiced by physicians. As anybody in clinical practice will tell you, Bob, "training" plays only a small part in success of community-based practice. To succeed in private practice, one needs a lot more than just clinical competance; and eventually most patients and almost all payers, will choose lower cost over higher educational/skill levels when it comes to primary care.

The ACP still has time to change course, if it values its membership's opinions.

Patrick Baroco said...

Nice challenge... But yes, I have confidence in my own training. I genuinely believe that the advantages of an internist's training over that of a NP would be clearly demonstrated in any system that carefully measures outcomes. It's the part requiring trust in the system to accurately measure things that bothers me...

The Happy Hospitalist said...

There are no internists entering primary care. They are all becoming subspecialists or hospitalists.

For those that remain, the question is moot. You're asking whether you believe seven years of post graduate medical education adds any thing of value that a BSN + 1000 hours of clinical experience doesn't for outpatient clinical medicine.

If you have to ask the question, either we aren't measuring the right stuff, or medical education is a scam perpetuated for centuries.

I have full confidence that my knowledge base in diagnosis, evaluation and treatment is exponentially expanded in scope and techincal skill when compared to the NP training experience. How do I measure it? Oh, I don't know. Perhaps a multiple choice exam.

The question is, does my expanded knowledge base add anything of value to the outpatient primary care experience. And can it be measured. Perhaps internists are just too qualified to manage the things we choose to measure in outpatient medicine.

roger said...

"Do you believe that internists will be able to demonstrate the value of internal medicine training, even when compared to NP-led medical homes using the same evaluation benchmarks?"

I think probably not. Our measurement tools are too blunt to demonstrate the difference between physician practices and NP practices, since 85% of the time (or so) there is no difference. The other 15% is very important, but the signal to noise ratio will be too high to demonstrate the difference, especially when the most important differences (diagnostic acumen) are not even among the quality measures.

DrJHO7 said...

It depends what is measured. If you measure HbA1C's in diabetics, readmission rates in CHF pt's, ER visits in asthmatics or BP levels in hypertensives, these are all rote, surrogate markers that are measurable by virtue of the fact that they can be measured and recorded. A PCMH that does its record keeping via registry or EMR, and acts on the results of reports by instituting patient management changes when indicated can likely demonstrate desirable results, no matter who's running the ship, be it an internist, family physician, nurse practitioner or yes, perhaps even a caveman, provided their training and experience in these given areas reaches a certain level.

I believe that the difference an internist makes is in alot of the stuff that can't be measured - varying clinical scenarios in unique patients that require a diagnostician - a physician - one whose depth of clinical experience and knowledge allow her/him to notice subtle history points or signs, or to customize treatment to individual patients to optimize their outcomes. There is no substitute for a medical education.

What should also be looked at are differences in referral rates from NP's to specialists, differences in the frequency or type of imaging studies ordered by NP's who practice medicine independently, PCMH or not, compared to those of physician practices in the same locale. This would be interesting data, but I too believe it is a moot point.

The numbers of NP's who choose to run independent medical practices will be negligible, and if they choose to do so in underserved areas, terrific. If they choose to do so in non-underserved areas, do you really think patients are going to flock in large numbers to nurse-run medical practices for medical care when good physician practices are available? Let the states manage these issues at the state legislative and licensing board levels with input from the medical profession - different states may have different needs and different solutions. Nationally, we've got bigger fish to fry in this health care reform debate.

Unknown said...

I am an NP. I believe MDs and NPs should work together to provide comprehensive care. Make no mistake NPs are completely qualified to provide primary care. NPs know their individual scope of practice. NPs should not be under the supervision of MDs. Collaborative relationships are acceptable for referral, but making them required has made no difference in outcomes. The only thing it has done is ensure that costs go up because of redundant, unnecessary oversight.

There is 30 years worth of clinical research that proves over and over again, even research from the AMA, that says the same thing outcomes data for MDs compared to NPs is equivalent in every way except one. Patients usually like NPs because they take a little more time and explain things. No doubt MDs are faster, we'll give MDs that one. Patients want to be included in the plan of care and by in large -not always but mostly MDs make decisions for patients. Just like right now every comment posted before this is about how MDs should run things. Well from where the American public is sitting they are running healthcare -right into the ground by overzealous individuals demanding more money to be in charge.

The state and national medical associations have intentionally limited entry into medical practice for decades, so long that there is a profound deficit of MDs. The associations have artificially limited supply side to cause an artificial economic upset. MDs want to be in charge of something -stop limiting the supply just to make more money. People -real human beings are sick of not having access to healthcare. I hear all the time about healthcare rationing. Right now some 48-75 million Americans can't even get an MD to give them a Tylenol. The whole profession should be ashamed!! People come to MDs they are nice because they are afraid & because they have no choice.

If what MDs do is so great so much better than what an NP does then none should be afraid of a little competition. Quit being a bunch of babies and man up.

PCP said...

To Nurse,
Man up? Go and crawl back into the space you came from? Your views are skewed by your own desire to legislate/lobby your way into autonomous care rather than educate yourself into it.
Understand that more than 50% of graduating medical students today are women. Understand too that, they are more represented in primary care than anywhere else in the profession.
You exist only because of the extensive and arguably over specialized way of the health care delivery system in the USA.
Many of us have long argued that the ACP and General IM was making itself less and less relevant by carving out various sub-specialties from itself for the past few decades. The latest being the hospitalist trend. The resulting work being mostly care coordination for which an entitled ANP would feel him/herself adequate. That however does not define a General Internist role unless he/she chooses to limit themselves to that. If we are to truly recognize value in health care delivery, then part of that will be to restore General IM to its roots, and in this regard ANPs pale in comparison.
As to your assertion that the AMA has kept medical school enrollments artificially low. That too is laughable, since the USA has amongst the highest density of physicians per capita in the world. It is just that our physician manpower is excessively skewed toward specialty services by about a 2:1 margin compared to a 50:50 split in most developed countries and furthermore it is maldistributed.
You appear to have no rationale to ANP parity than to "dumb it down". I have worked with ANPs, and for a lot of care they are adequate, however I can assure you, one does never know what one does not know. That is as true for ANPs as it is for a General Internist.
Albeit one can be sure the General Internist has a higher level of knowledge, experience and cognitive wattage, by virtue of pre-entry academic qualification, education and training. If NPs wish to argue with that, that is up to them and their disingenuity. Once again I reiterate, it is precisely because our health care system has become way too over specialized that you and your lobby has come to see their role as primary care gate keepers. I disagree that Primary care medicine should be "dumbed down" further. I believe en contraire that its status should be elevated.
I can't imagine that a CT surgeon speaking with a NP is going to think of you as much more than a nurse. On the other hand were I to try to weigh the evidence and recommend medical therapy vs surgery the outcome may be different. That is quite simply because I have earned my right to peerage and you would have legislated your way to it.
If your argument is that doctors spend too little time with their patients we can agree upon that, but here too we disagree on the underlying reason for that, it is worth considering, IMHO the Insurance industry and CMS with their unfair assignment of value to cognitive OP care are causal here. IMHO, your nurse services are over valued at 85% of mine and mine are undervalued compared to my specialist peers. If you were at a value commensurate with your education and training a value of 50-60% would be more appropriate and much of this discussion would be moot. Yet I know you feel entitled to 100% and that is more apt.
With a more accurate representation of value, I too can take my time and the patient would be getting more of my time. They would probably also be getting better and more comprehensive care as well.

PCP said...

To nurse,
Go ahead and delude yourself that you are the safety net of health care.
The truth is that most indigent care is provided through the compassion of doctors and in the ERs of hospitals. If you want to drink the kool-aid that your lobby feeds you then that is your choice, however the amount of charity care provided by Physicians ought not to be underestimated.
You represent exactly the sort of destructive force that I have long warned the ACP about.
You are no competition to me, you merely represent a phase we must travel down as a country to learn the hard lesson that quality primary care must be physician led. Apparently the lessons of the pre-flexner era of medicine have been lost and the errors must alas be repeated.

I'll leave with a brief anecdote that gives me conviction on this issue.
7 yrs ago I was recruited out of residency to a FQHC. That FQHC had a part time retired GP and 3 mid levels working with him for a very ill cohort of patients, multiple chronic illness minority population of indigent patients. They had on average 8-10 inpatients in the hospital on a daily basis. The local Private doctors complained to the hospital about their indigent care burden and(probably as a result) I was recruited.
Half of my day would be spent in the hospital. I could not give the OP side my full attention. Finally I convinced them to hire a colleague. We collaborated amongst ourselves and with our mid-level colleagues and built a exceptional team including committed RNs, CDEs and even got a podiatrist and some specialists to come in a half a day a week. We were down to 2-3 in patients a day within a couple of years. Absent Physician leadership I assure you that would not have happened. Much has transpired since those early days, but that experience assured me of my place in the health care system.

Any systemic reform that fails the General Internist in the upcoming debate on health care reform is doomed to fail. Of that I am certain. The General Internist remains the best value in health care today. I hope the pragmatist in Obama sees that. That value must be unlocked. For that we must fight.
Once again to the NP audience, I hope you understand, you have your role in the system, but try not to exceed it.
Collaborator you can be, competitor you are not! The NP lobby has never understood this basic fact and hence has contributed to the fragmented messy system we have.

Unknown said...

I think it will be pretty hard to show with hard numbers what we can do that NPs can't. I feel like we all know that we can offer a greater depth of knowledge, and when we interact with NPs we can see it. But I don't think that we can prove any difference in any of the outcomes we can easily measure. Everyone keeps saying that some horrible outcome will happen because an NP missed something. The truth is that there are plenty of horrible outcomes where an MD missed something.

I do think we can offer our patients a wider spectrum of services, such as inpatient hospital care. As we have left hospitals en masse and allowed ourselves to become primarily outpatient providers who have to see dozens of patients daily to make up costs, we have lost what distinguishes us from NPs. Not only do we no longer round in the hospital, but we also don't spend as much time with patients, out of necessity to keep our practices solvent.

I think the ideal model is a team approach; the MDs take care of some of the less sick patients and all of the more sick patients, while the NPs take care of the well patients and refer to us when their symptoms fall outside of the standard. We do have to be careful that we don't become overwhelmed by the complex patients who take a lot of our time and do not bring the reimbursements necessary to keep a practice running.

NPs in practice without MDs? I hope not. Their training simply is not rigorous enough or long enough to allow them to practice fully independently.