The Blurry Line: When non-physicians practice medicine

It used to be that there were well defined roles.

Pharmacists dispensed medications on the order of a physician.

Nurses carried out care and healing as ordered by a physician.

Physical therapists helped patients heal their bodies on the order of a physician.

Physicians practiced medicine.

But that's all changing.  There is a hurrying pace to expand the scope of practice of non-physician providers to include elements of medical practice. The purported reason is the lack of availability of primary care physicians and access to care.

But, honestly, like almost all things in America, it's really not that altruistic.  It's about money of course.

And since it's about money, I've always been curious about the public's willingness to pay for information, time, or care from a non-physician provider at the same rate as if they were paying for a physician.

And when the stakes are high, like with your own health care, it looks like most people would only want the "best."

Now before I start getting hate mail or malicious tweets from the host of non-physician providers out there, I'm sure there are some in that group that practice good nursing, pharmacy, physical therapy, etc.  That's not what this is about.  I'm talking about medicine.

I'm sure if the airlines decide that airplanes have become sophisticated enough that flight attendants can be cross trained first as copilots and eventually as pilots, then the issue will become clear.

Someone once told me that to get hired by Southwest Airlines as a copilot in a 737 that it required 2000 hours in type and experience as pilot-in-command.  This is a hefty requirement but probably why the airline has one of the best records in the industry.

Now if you were to train a flight attendant with a fraction of that time, let's say 200 hours, would you feel as comfortable in seat 6B?  Even if your flight was on-time, everyone was friendly, and you had peanuts and a drink coupon?

But the analogy fits very well with medicine.

Let's take nursing:  its become somewhat politically incorrect to consider nursing any longer as a support role in health care.  There has been considerable growth in the industry in the role of becoming primary care givers.

Many states leave the determination of the scope of practice to the state nurse licensing boards which gives them broad latitude in defining what nurses can and can't do.

Much of this depends on the definition of the "practice of medicine" which has always been understood as the "diagnosis and treatment" of disease.

So nursing boards have morphed a term now to include the title: nurse practitioner, or NP.  These "advanced practice nurses" usually have expanded training, mostly from other advanced practice nurses  and some physicians, in the area of diagnosing and treating basic ailments.

Supposedly.

I say supposedly because there are very few if any statutory limits on these advanced practice nurses.

Think for a minute that it might be one thing for a flight attendant to fire up the plane and taxi out to the runway, but it would be quite another to take off into the fog and rain of a messy evening.

So these APN's go into practice and begin to practice surrogate medicine.

The confusion abounds with patients who don't always know the difference from one provider to the next.  They just know their little girl has an ear infection and needs an antibiotic.

These lines even get blurrier when programs begin to offer "Ph. D." course work in nursing which then entitles the person to be referred to as "Dr. APN." Patients become confused:  just who is a "doctor" any more?

Now most of these non-physician providers are supposed to be either supervised by a physician or they are to practice under specific guidelines drafted and overseen by a physician.

But it is clearly not the same as having a physician see the patient or being immediately available for consultation.

(Think for a minute:  that flight attendant could always radio in for help....if they were to get into trouble...)

Many physicians like using non-physician providers of care because it increases through-put and therefore revenue for the practice.  These environments often deliver superb care in a team environment managing complicated patients.

Physician's assistants are one of the best examples of how the system can work well.  Usually these mid-level providers train directly with physicians, are regularly supervised, and have academic backgrounds that ground them in the basic science of medicine.

This type of preparation and apprenticeship is often lacking in other non-physician provider training programs.

But when advanced practice nurses want to open up a clinic and begin to practice primary care medicine, you really have to wonder if this is a good idea.

It's a slippery slope where most of the time no one gets hurt.

Pharmacists in many states can now give vaccinations and maybe even adjust the dose of someone's insulin to treat their diabetes.

Physical therapists may be able to diagnose a knee strain and begin corrective exercises and rehab.

Advanced practice nurses may be able to diagnose a sore throat in a 3 year old and start antibiotics.

So where does the slope end?  Despite the fact that medicine is becoming even more technical, the number of drugs is expanding at an unbelievable rate, and patients are generally sicker now than in the past (particularly with the economy challenging access to preventative health care services), there is a growing feeling that we need more non-physicians delivering health care.

And because of the purported need for access to primary care, legislatures are changing the statutes and regulations to expand the scope of practice of these non-physicians.

Physicians in the United States on average have completed a four year basic science undergraduate curriculum, four years of medical school, and typically 4 to 5 years of post graduate training in an internship and residency.

Most advanced nurse practitioners complete about 5 to 6 years of training total -- at least of three of which is spent solely in nursing.

So can a legislature obviate the need for medical school just by changing the law?  Of course not, but that is what is happening in many states around the country:  nurses, and other non-physician providers, are seeking independent practice.

This independent practice would remove even cursory physician supervision of their treatment of patients.

If lowering the standards was all that was necessary,  then one solution for the crisis in primary care access would be to shorten the requirements for physicians going to medical school.  I know, that's absurd.

With the technological advances in medicine and particularly surgical procedures and medication treatment -- the course of study cannot be condensed.

But to complete the tale of a story gone wrong, many advanced nurse practitioners never practice primary care. Instead they take up the practice of aesthetic medicine such as treating patients with cosmetic drugs like Botox or lip fillers.

To be fair, all of these non-physician providers in the proper setting offer advantages in our current health care crisis.  Working in a team under the supervision of a physician, health care delivery can be enhanced, access can be improved, and patients can get better service.

There is no better example than that of physician assistants.  This relatively new type of non-physician provider is probably the model that needs to be followed in expanding the scope of practice for medical providers.

Physician assistants usually complete a six year curriculum and even then there is typically a post graduate practicum or   on-the-job training program directly with a physician.  These professionals work hand in hand with physicians in caring for patients, have privileges to write prescriptions and perform some surgical procedures, and can help the physician in coordination of care for the patient.

In most states they are even supervised by the physician licensing board.

But as a rule, they don't have independent practice.  It is the perfect model to expand access of quality care.

Now, I'm usually a self-described progressive, and I'm always open to new ways to educate and treat patients.  But the last thing I want to do is to put patients in harm's way.

We shouldn't allow the access argument to blur the lines of right and wrong so much that we allow the training of our health care providers to be diminished.

If you want to practice in a support role working hand in hand with a physician to provide quality care, I'm all for it, and will work and lobby to make it happen.

If you want to practice medicine independently, then go to medical school.

Injections: Does hurting children now, hurt their health care decisions later

For a long time I ran a large multi-specialty group medical practice in a relatively small town. One of our most active divisions was pediatrics.

Ruby was a nurse in the department for almost 30 years and she had seen probably half the community's children grow into fine healthy adults.

But one day I ran into Ruby at the local Walmart about the time that a group of small children rounded the corner. I also stopped to visit with the nice lady.

The children, though, turned, ran, and cried to their mother.

Ruby commented to me that this was a common but unfortunate occurrence for her.

She was the "shot lady."

Hypodermic injections are one of the earliest memories that children have about health care. In fact, if you ask a young child about the necessity to go to the doctor, the child (and many adults as well) will respond, "I don't need a shot."

Physicians, nurses, and mothers over the years have devised a whole host of tricks to encourage children to get the needle.

Bribery is a favorite of mine: "we'll go get ice cream," "we'll stop on the way home and ...", or the most recent experience for an 18 year old in my office -- "we'll stop at Nordstrom's and get your makeup done."

Threats seem to work for some children. It usually is a threat about "worse pain" than the actual injection. If children are old enough to reason even a little, then the fear of being beat with a belt is usually enough to motivate one for the measles shot.

But it doesn't always work that way. A couple of years ago a father threatened to whip a 14 year old in my office if she didn't submit to an injection.

(Just for the record, I'm opposed to corporal punishment.)




Some nurses and parents are particularly good at trickery. Either there is a ruse on coming to the doctor in the first place ("mommy is here to see the doctor" only to find out that "little Johnny is getting a flu shot"), or my absolute favorite: "this won't hurt a bit."

Well, it never hurts me.

Sometimes health care workers can't bring themselves to completely lie about the pain, so they'll compare it to something more familiar and hopefully more palatable.

Like a bee sting.

That one always makes me calm down.

"Yes, it will feel like a small furry creature is inserting a stinger into your skin and blasting poison away."

You're calm now, aren't you?

Brute force is sometimes an option, particularly if it's a young child.

There is a device for young children called a "papoose board" which is a politically correct way of saying "straight jacket."

Children are strapped in the device which has various holes and openings that allow physician or nurse access to desirable locations -- like those for an injection.

This isn't effective when children get above three or four. They are just too strong and our staff and parents are too weak.

Attempts are sometimes made with this modality and usually everyone ends up in positions that would rival team wrestling at the Dallas Sportatorium.

Negotiation is sometimes employed, with very mixed results (usually followed by one of the items listed above.)

You see with injections there's really no "compromise." So negotiation is doomed from the beginning.

You can't end up only "injecting the needle a little bit" or using a "very small needle" or avoiding the injection altogether -- which is the only solution that most children will agree with.

But in the end, most children are traumatized in some way by the experience. I'm not saying that they shouldn't be receiving injections, rather I'm just saying most children leave with short-lived tears and long-term fear of physicians and going to the doctor.

So the question is does this affect their desire to go the physician later in life for regular, and possibly preventative health care?

Particularly if the primal image of your first health care experience is clouded with pain.

Do you put off the flu shot? The breast exam? The prostate exam? Just your annual physical because of some underlying deep seated sub-cortical negative early experience.

I think many patients do.

Going to the doctor is often a painful experience. Some things just hurt.

But I do believe that anything that physicians and nurses can do to mitigate the pain has a positive effect on that person's future health care decisions.

I like to compare it to swimming. As a scuba diver and water lover I think it's essential for children to learn to swim.

Aside from the obvious reason that it helps to avoid drowning, it also opens up a wonderful world of water sport experiences that otherwise might be avoided.

Children who are taught to not to fear the water, but learn how to interact with it in a positive manner -- playing, floating, blowing bubbles -- usually learn to swim quickly.

Their fear is gone and what comes with it is a learning that water can be safe.

Health care is no different for children.

If they are taught that physicians and nurses shouldn't be feared, then the overall calm atmosphere raises the pain threshold for the children.

Anxiety is the biggest cause for most pain. Children, and even adults, have "fear of pain."

Teaching patients and especially children that pain does occur with procedures but you are there to help them with it can go a long way to prevent an adverse outcome.

Of course, some children are just too small to be able to understand, or they carry with them feelings and fears from other providers into the office. In that case it's, of course, more difficult.

In our office it  is important to me that children have the least pain possible and the most positive experience. If we can find a less painful solution, we try to do that. If it's impossible, then we explain the procedure, and the pain, and we work with that patient to make it as comfortable as possible.

I would love to hear from parents and providers on their ideas and solutions to creating positive interactions with children and painful procedures. I'm sure I have a lot to learn.

And I don't want children to run away crying when they see me at Walmart!


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Location:Dallas, Texas