Friday, June 11, 2010

Why Nurse Practitioners Don’t Scare Me

A lot has been said lately (finally) about the apparent ascendancy of “mid-levels” – a fancy name for Nurse Practitioners and Physician Assistants – into a position from which they could challenge actual doctors (M.D.s and D.O.s) as Primary Care Providers (PCPs).  I’ve been talking about this since the beginning of this blog, and I’m glad that others are getting on board.

This fear has been heightened by a couple of recent developments.  First, there is the even greater aggressiveness of mid-levels, especially Nurse Practitioners, in staking just such a claim for stand-alone privileges.  They have now gone so far as to crassly start calling themselves “Doctors” through a clever little trick of making their relatively brief training result in a “doctorate” degree – the D.NP.  Second, there is the new health care bill, which promises to dump tens of millions of patients onto a primary care network already strained to the breaking point by years of neglect and financial attack from third-party payers, especially the federal government. 

The concern boiled down is that mid-levels will push doctors out of the PCP business.  There is reason to be concerned.  Originally conceived to help ease the burden on PCPs touched on above, but now being paid 85% of what their doctor counterparts receive from Medicare, mid-levels have definitely begun to challenge their role as mere physician “helpers” and are now pushing – through their extremely powerful and even more extremely vocal unions – for more and more authority.

I have spent years in fear of this scenario.  It won’t just be bad for doctors.  It will be bad for patients.  Nurse Prac…er…  “Doctors of Nursing” simply aren’t trained like doctors.  Neither are Physician Assistants – who, by the way, have their own lobby which is now pushing for them to leave behind the “assistant” part of their title and be called “Physician Associates”.  Ugh.

I have had a bit of a change of heart, however.  Don’t get me wrong – this whole deal is unbelievably unfair.  To ask people to give up 12 years of their life to become “Board Certified Family Physicians”, and then to allow someone to do their job with less than 1/3 of the time spent and less than 1/10 of the money spent is simply obscene.

But here’s the thing.  I am a good doctor.  I work hard to be good at what I do.  And I challenge any Nurse Practitioner or Physician Assistant to do my job better than I can.  They won’t be able to.  At least not with the kind of consistency that will make them able to steal my patients.

I feel confident in my abilities.  I don’t have to refer every sore throat to an Otolaryngologist.  I don’t refer every diabetic to an Endocrinologist.  If insurers and the government think that a PA or NP can do my job cheaper than me, let them wait until they start to see the bills from the multi-specialist care those patients will receive.

If insurers start paying NPs and PAs like doctors, or start pretending they are doctors on par with me, then I will stop accepting that insurance.  I am confident that my patients would rather see me than a nurse or PA.  In fact, I am working overtime just to ensure that patients know the difference and can tell their insurance company (or the federal government) to stuff it if they go this way.

I’m not depending on anybody else to protect my job.  I can do that on my own.  Is it fair?  Of course not.  But nobody ever said life was fair, and as a self-sufficient Southerner and American, I specialize in winning unfair fights.  Try and beat me at my own game, nurses.  Do it without your union and without the government having your back.  Do it on your own, like I am doing it, and then you’ll be worthy of the title “Doctor”, and not have to steal it through word games or trickery or political slight-of-hand.

The gauntlet is thrown down.  I challenge you.  But I don’t fear you.  You haven’t earned that yet, either.


This may be my favorite Doc Zero piece of all time.  It’s been a while since I felt a giddy rush of excitement, but this tirade delivered just that.  Feel the terror, bureaucrats.  Feel it.