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April 14, 2010

Md. should make nurse practitioners independent

Nurses are probably already the hardest working people in health care. Nurse practitioners -- highly trained professionals who increasingly function as doctor proxies -- are surely going to be part of the solution to the health care crisis. Especially if pay for primary-care doctors continues to lag that of specialists. In 2008 median primary-care doc pay was $186,000, according to the American Medical Association. Some primary care docs make much less and have hundreds of thousands of dollars in student loans to pay off. So fewer and fewer med school students are going into primary care, even though primary care docs -- who keep people well instead of treating people after they get sick and charging for procedures -- are what the system needs.

Nurse practitioner pay, at a median of $83,000, according to salary wizard, is approaching that of primary-care docs.

It's nice that the General Assembly cut the paperwork needed to become a nurse practitioner. But it will do little to increase medical expertise where it's needed. The legislature should have allowed nurse practitioners to eliminate ties to doctors altogether and practice on their own. But it caved to pressure from Med Chi, the Maryland doctor trade group concerned to preserve the monopoly of licensed physicians. Washington, Oregon, Alaska and seven other mostly Western states (rural states where docs in the backcountry are scarce) already allow independent N.P. practice. So does the District of Columbia.

Posted by Jay Hancock at 9:14 AM | | Comments (26)
Categories: Health Care


Nurse practitioners are not only cost-effective, their patients are more satisfied with the care they receive over that received from the primary MD. There are many research efforts that have shown these results. NPs go through a rigorous education and training and are competent in providing health maintenance care as well as identifying and treating deviations from the norm. Once a problem is found, they can treat it or refer the patient to a physician for follow-up. Most of the primary care MD's I have known recently are willing to identify a problem, but immediately turf it to a specialist rather than spend the necessary time to treat it themselves. Could be that the compensation for such treatment is not worth the time and effort. So the outcomes for care by a NP vs. a primary care MD seem to be similar, except the NP will actually do more of the care. To me it's a no-brainer.

The objections of physicians to independent NPs have nothing to with preserving the monopoly of licensed physicians. When there is no physician available, then an NP is reasonable but an NP must not be completelty independent as they do not have the necessary medical training. Important diagnoses will be missed and incorrect diagnoses are more likely if NPs are completely independent. Such is not the standard of care we have come to expect in US medicine.

Thomas Reid MD
Hematology-Medical Oncology

So what is going to keep or incentivize these "independent" NP to go into primary practice or go out into the rural areas where primary physicians are most needed?

The solution seems simple...if NPs want autonomy, take the United States Medical Licensing Examination (USMLE)!

In response to Dana, they tried something like that:
This was only a simplified version of step 3 (which i'm told is the easiest step).

There is even a bigger shortage of nurses. perhaps these nurses should worry about that and let doctors take care of their shortages. no, thanks but no thanks. !

rigorous training?! an NP has mostly on the job training...they NEVER went to a formal hard-to-get-into school like medical school. I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpining principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive.

you don't have to have 'MD' behind your name to provide competent health care. All health providers should be held to the highest standard. Many RN's are capable of providing a significant amount of independent care, especially as teachers of health care. We need to look at the bigger picture and not just our own self-serving views, esp. if we want to improve primary health care in the U.S.

In response to Dr. Reid. I work in a practice where the NP's have caught several diagnosis missed by MD's. Also, I think it says so much that many of the MD's patients in that office no longer choose to see him, but would rather see the NP.

To Dana and George, what would that prove? We are not licensed by the board of medicine and why would they license us? We have not studied the medical model of care, but the nursing model of care. George is correct, they have tried that. Would you suggest that pharmacists that practice and prescribe medication (which is currently the ONLY thing some states require) take the same test? Seriously, move on people! There are so many patients and so few providers. If you channeled your energy into improving your relationship with NP's we could make such a bigger difference rather than fighting and dumping millions into a campaign...

In response to Susan, the reason primary care doctors refer their patients to specialists is due to the high standard of medical care that patients, and especially their lawyers, demand. You cannot expect an NP (with MUCH less rigorous training) to provide the same level of care or carry the same responsibilities as a physician. I can't imagine the number of lawsuits that would follow.

To Ryan, pharmacists DO NOT prescribe medication. That is for physicians that do have medical licenses and pass the USMLE. Why would this test exist if it was not essential for adequate care?

So if NPs take and pass the USMLE would it satisfy you that our education is "rigerous" enough?
We have board certification for a reason. I would put my knowledge up against any MD in family practice. Bring it on!

Teri Bunker, FNP, BC

If NPs want to be independent, then they should learn just as much of the science of medicine as we do as medical students. I have a degree in biological sciences, and now am learning rigorously about biochemical, cellular, tissue, organ, and systems based knowledge that I will need to keep patients healthy and treat and diagnose those who are ill. I will need this knowledge to pass the USMLE. So if an NP can pass this test, this shows that they have the knowledge base to be independent health care providers. Otherwise, they are an excellent support to the healthcare system and are well compensated for this support.

Sure, if NPs take and pass the full USMLE that would qualify them on some levels to be independent. The point of medical school is to pass this test.

NP board certification is for just that, an NP career. It does not qualify one to run an independent clinic which is the argument here. I'm not denying the importance or competence of NPs in our system, but no one should be practicing alone without proper licensing.

I feel so foolish for going to medical school thinking that I need that level of medical science education to obtain the expertise and experience needed to fully diagnose and treat patients! I see now that the four years of medical school and 3+ years of resident physician training provide no real advantage over a 2 year graduate degree program.

All kidding aside, I realize that the number of patients will swamp the medical field if not soon then in 2014 when additional patients will obtain health insurance after the health care reform bill takes effect. NP's along with PA's will be valuable, but their level of training is not as extensive as an MD (or a DO). Without as strong of an educational background, why do you think that NP should be equally qualified to be independent practitioners?

The framework for producing independent physicians who are qualified to diagnose and treat patients already exists. If you want the responsibility for yourself, all you need to do is apply and then prove to the medical board that you are competent.

Nurse practitioners, and other health care professionals who are not doctors of medicine (MDs) or osteopathy (DOs), are critical to meeting the growing needs of patients and, time and time again, research has substantiated the quality of care these professionals provide. As coverage expands under health care reform, access to care providers will diminish unless our policymakers advocate for regulations that promote quality and patient choice. Physician professional societies need to stop wasting valuable resources pressuring lawmakers to restrict the care that these highly-trained professionals provide, and do more to promote a collaborative environment that serves the interests of patients. For more information, you can visit the Coalition for Patients’ Rights’ Web site at:

Look at the studies that consistently show that nurse practitioners provide competent care comparable to that of physicians.
To the skeptical med students out there, do physicians have their limits? Can an internist do arthroscopy on a knee? Can an orthopedist treat a pt with CHF? Can a dermatologist perform a competent pelvic exam? Is my point made? Hopefully, all of us in health care recognize we cannot know everything. That includes physicians as well!

Does anybody know of a website where the Pearson Report can be accessed without charge?

For the doctors who continue to post that NPs should "go to med school" in order to be able to practice independently, you are entirely missing the point. Of course most of us could be medical doctors if we chose to, but we don't. We choose to be part of the very honorable practice of Nursing. The common fallacy behind most of the "pro-doctor" comments is the beleif that physicians have some kind of guaranteed monopoly on the practice of diagnosing and treating illness. You don't. The Nurse Practice Act in my state (and many others) already allows NPs to do both independently. Though many of you are clearly threatened by advanced practice nurses, the train has already left the station, as they say, and it isn't coming back just because you don't like it.
In 30 years as an RN, I have worked with (obviously) book smart MDs so completely stupid I wouldn't take a hamster to them for a hangnail. Like the one who insisted that the urine saturated diaper pieces clining to an infant's bottom when the diaper was first removed were yeast. He prescribed an antibiotic for the equivalent of toilet paper stuck to a patient's butt. Or the new M.D. who insisted that a 24 week gestation fetus wasn't viable so the "fetus" should be delivered in the labor room and provided no resusitation --nevermind that the mother was confident she was 28 weeks pregnant and that the ultrasound was wrong. I tried to reason with him -- diplomatically and discreetly provided him every "out" -- every way to change his mind and give a different order without losing face. He would rather have died. Turns out the baby was, in fact, 28 weeks -- viable! Thank God I didn't listen to that oh-so-competent and qualified-to-diagnose physician. He was so mad when he was called -- he came to watch the "fetus" die and instead found us "less educated" highly specialized OB and NICU nurses resusitating and supporting the life of that little patient. Oh, yes, he had some choice words -- lamenting the terrible plight of being a real doctor who had to put up with "nurses who think they are doctors." And yes, he said it all in front of the patient. No matter -- 10 weeks later, the parents brought their entirely healthy, beautiful, little Kimberly by the OB nurses station on their way out the door to take her home. That doctor was not stupid, he was arrogant and unwilling to learn from "less educated" people. He graduated from medical school; he passed all three steps of the USMLE; he had a license to practice medicine and he was incompetent. Fortunately a Registered Nurse with a 2 year degree stood up to the pompous ass and saved that baby's life. Every nurse I know could tell dumb doctor stories all day long....your arguments for the superiority of an MD simply because he or she has a medical license has no credibility whatsoever.
The bottom line is this debate is all about money. Doctors simply don't want to lose their place in the food chain, and whether you will admit it or not, that is the ONLY reason an objection to independent NPs makes any sense at all.
I hate to be the bearer of more bad news, but there are always going to be very smart people with "lesser" degrees, and with less time and money invested in their careers who find a way to make more money in the medical field than the average doctor. I became a nurse when I was 19 and worked my gluteus maximus off to pay of my $5,000 school loans within a year. 7 years later, with my inferior degree and $30,000 in savings, I started a business in the medical field where I eventually earned more money than most of the doctors who sent me referrals. I sold that business and retired, debt free and financially independent for life at age 45.
I'm now finishing up my Masters Degree and will soon be a proud NP. I will be going on to get my DNP, so brace yourselves, docs, not only will I be diagnosing and treating patients independently, but my patients will be calling me DOCTOR Velagas. Don't worry, I would NEVER want them to think I am an MD; I'll be the first one to tell them with pride that I am an NP and an independent Doctor of Nursing Practice.

I agree 100%.

Nurse practitioners practically are doctors. With so many specialties these days, I don't really see a need for 4 years of medical school anyways. We should just cut it by a year or two and let people specialize to save time and costs.

I think NP's are going to become more popular in the future too.

VERY well said, vitruvian! I'm one of those NPs who practices "independently." By that, I mean that I own my practice, but have to pay a physician to review 10% of my charts every 30 days - the biggest waste of money ever! Of course, by the time she reviews them, the patient is long gone, so all of this makes absolutely no sense. Except to the doctor who gets the $$$ for spending an hour of her time reading charts!

For all you doctors out there who think we need someone watching over our shoulder, let me tell you about a few things I've witnessed over the past few years. How about a doctor who prescribed Keflex monotherapy for a patient with diverticulitis (diagnosed on a CT scan). Thank God he came back and saw me a few days later. He informed me that the abdominal pain had subsided, but he had this weird pain directly under his diaphragm. Thank God I figured out he needed an x-ray and saw all that free air in the abdomen.

How about the doctor who kept telling a patient (over a one year period) that the bulge in his inguinal area was a hernia and not to worry about it unless it started causing him pain. Thank God he got to see me and mentioned it in passing - it turned out to be an enlarged lymph node. He was diagnosed with Stage IV Hodgkins lymphoma soon afterwards.

How about the patient who complained of dizziness for several months, yet her doctor never bothered to listen to her carotids? Thank God I was precepting as a NP student that day - her carotids were 85% blocked. The cardiovascular surgeon told her to thank me for saving her life.

These examples involved 3 different board certified physicians - 2 family practice docs and one internist AND they were all educated in the U.S.

I could give you so many examples of how I, an "under-educated" nurse saved the day, but I would end up with carpal tunnel by the time I finished.

Make no mistake, this is ALL about money and has NOTHING to do with patient care. If it was about patient care, we would have full independence in every single state!

While reading all of these posts several things become abundantly clear to me immediately. First, I think that what EVERYONE is missing here is that the only way to foster a positive therapeutically successful reciprocating relationship with the patient is to recognize the importance of every professional in the chain, from the nurse to the doctor to the pharmacist. Secondly, I think that the nurses and NPs that are posting examples of MDs who have miss diagnosed patients kind of cements the points of the MDs who are concerned about the "lesser" educated NP being given autonomy. That is, those outliers are just that, and are not indicative of, or proof that, NPs are qualified to practice alone. You can't use a few incidents that are outside of the norm and use them as proof that NPs are just like doctors. If you went to Med school where the scientific model is taught you would realize this. I could say the say thing by using my pharmacy experience, for example I have to call and provide professional intervention or inform of mistakes and dangerous interactions on prescriptions written by NPs way more often that on scripts written by MDs, DDS, or DOs....I agree with the doctors on this if you want to practice and prescribe independently....GO TO MED SCHOOL

This is how it should be.... If you want to practice medicine with independence get and MD or DO. Too much diploma creeping going on today. What's the point of even getting an MD if you can just get a nursing degree and do the same thing? At some point a line needs to be drawn.

My last comment was sent from my phone and as a result is full of typos......What I was trying to convey is this. I have had a problem with Nps for quite sometime. Personally, I dont think that they should be given ANY prescribing rights at all until they have earned a similar education. The Nursing education is just that, and does not require the same background or dedication to learning the scientific model. Further, while I have heard many nurses and NPs discussing their frustration with doctors, and trying to illustrate their competence by pointing out the mistakes of doctors, that approach seems utterly silly and really demonstrates their lack of scientific knowledge and competence with statistical analysis......

So, NP logic really boils down to, "I've seen a few doctors make critical mistakes, therefore I'm qualified to practice medicine independently"? Hopefully I'm not the only one who's worried by the fuzzy logic there. Non sequiturs, anecdotal evidence, and straw men do not a competent argument make.

This is not about money.

Shall we also allow paralegals to represent us in court? Should I be comfortable with my hygienist performing my root canals?

I do not deny for a moment that nurses in all capacities provide a critical service in health care, and I do not mean to denigrate that service. I would happily defend their right to practice NURSING, as that is their training and chosen profession. Those who choose to become doctors have chosen an entirely different career - even undergraduate requirements are markedly different for pre-med students than for pre-nursing, so the training contrast is from the ground up. If you want to be a nurse, be a nurse, and wear the badge proudly, as you should. If you want to be a doctor, then be one. Just understand that it's an entirely different endeavor, and please, for the sake of the patients, don't allow your ego to take you into arenas in which you don't belong.

Put simply: If you don't have the skills, you can't do the job.

For further reading, please see "Dunning-Kruger Effect." The Wiki article on the subject illustrates the problem with the NP arguments presented herein from the very first paragraph.

As currently a nurse practitioner student, I have rigorously examined the role of the Nurse Practitioner in healthcare. After switching from a Biology Major to Nursing and completing my 4 year degree, I've been working in a Cardiovascular Intensive Care Unit, where I've been able to witness the relationships between physicians and advanced practice nurses/nurses etc. Personally I think this argument is a futile attempt for MDs and primarily students, to prove his/her superiority in the hierarchy of medicine.
What all of you medical STUDENTS don't understand is that nurses are taught under a completely different model of education. We are taught to look at the WHOLE patient, including his/her biophyscosocial needs. We are taught to therapeutically listen to each patients' concern and to facilitate coping and reacting to the diagnosis and treatment of disease.
Obviously, we have and are going to have a serious lack of coverage for insured individuals under the new health care reform laws. The AMA and other lobbying groups need to focus their attention to arguments that will actually contribute to solving the problem, instead of trying to prevent NPs from practicing independently. NPs are nurses who in most cases have firm nursing experience, who choose to further his/her education by obtaining a Master's Degree. Through this didactic learning and several hours of clinical experience, they are able and SHOULD be able to diagnosis and treat independently. I think what many people on this blog have failed to mention is that this by NO means equates to the absence of collaboration. No doctor knows everything. I work with Cardiothoracic surgeons who seem to think they are God, who are extremely weak with the management of medical conditions post-operatively. No NP is claiming to know everything, and the specialized NP strives to contribute to the health care team through collaboration.
To the pharmacy INTERN who so arrogantly explained the lack of scientific education obtained by nurses...I completely agree with your saying that mistakes witnessed by NPs are not sufficient evidence of the ability to practice independently. Their education, clinical experience and constant determination to provide good patient care through collaboration is the evidence the Nps posting on this blog should have chosen to provide. However, you chose to argue your opinion by offering the same "non-scientific" evidence. You offered an exception to the norm. Studies show that Nurse practitioners in regards to prescribing, are no less competent than physicians, and actually show to be more cost effective, as they will usually opt for the less expensive medications first. My husband is in his last year in pharmacy school and it's sad to see someone like you, having such cynical and close-minded points of view before ever even entering the real world. Everyone makes mistakes regardless of the letters following your name.
It's very disheartening to read comments made by medical students (our future doctors of america) that demonstrate this "old-school" narrow minded practice of health care. The NP/MD relationship has the potential to work like a well-oiled machine if the egos of these "highly educated" individuals would be placed aside and they would truly focus on delivering the high quality patient care with which they all seem so concerned.

Can someone tell me if there is a standard percentage that supervising physicians earn from NP's patient fees who are in private practice? Or if you are an NPin private practice, what your financial arrangement is with your supervising physician?

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About Jay Hancock
Jay Hancock has been a financial columnist for The Baltimore Sun since 2001. He has also been The Baltimore Sun's diplomatic correspondent in Washington and its chief economics writer. Before moving to Baltimore in 1994 he worked for The Virginian-Pilot of Norfolk and The Daily Press of Newport News.

His columns appear Tuesdays and Sundays.

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