‘The nurse will see you now’
Next time you’re a patient, ask whether your “health care provider” is a doctor.
On January 1, New York State changed the standard for who can practice medicine, putting patients at risk. New York is the latest state — now 19 in all — to capitulate to aggressive lobbying by nursing organizations to allow some nurses to play doctor without going to medical school. Connecticut made a similar change last July.
Don’t get me wrong. Nurses are the backbone of the health care system, and generally they’re better than doctors at educating patients and providing many types of routine care. But their training is different, and it does not prepare them to do everything doctors do, especially diagnosing less common conditions.
Yet under new laws, nurse practitioners can do everything primary care doctors do — diagnose, treat, prescribe and even open their own independent practices — once they’ve worked for 20 months under a physician’s direction. “Can” means legally, but it doesn’t mean they have the know-how. That’s the danger.
Nurse practitioners are registered nurses who have earned an advanced degree. But they’ve never been to medical school, they have half of the years of training a doctor gets (generally six years beyond high school instead of 12), and they don’t take the same state licensing exam as doctors.
So don’t assume they have the in-depth knowledge to diagnose your uncommon illness or handle your complex problem. Dr. Sandeep Jauhar, a cardiologist at Long Island Jewish Medical Center, criticized the New York law when it was enacted last April. Medical students with “two years of clinical training are not considered fit to practice medicine independently,” he warned, but in New York State, “nurse practitioners with perhaps even less clinical education will be allowed to do so.”
Lower cost is why health insurers, drugstore chains with walk-in clinics, and federal health programs applaud replacing doctors with nurse practitioners. The term “provider” was cooked up by HMOs to blur the differences between physicians and less expensive caregivers. Even the Veterans Administration is considering cutting its backlog by sending vets to nurse practitioners. But they don’t save money in the long run, Jauhar suggested, because they tend to order more CAT scans and MRIs than physicians treating similar patients, probably as a crutch to try to get to the right diagnosis.
A 2013 analysis in the New England Journal of Medicine shows why physicians oppose the change, and it isn’t to keep business for themselves. With the physician shortage, that’s not an issue. What doctors know is that nurse practitioners get less education in how organs and bodily systems work. They are trained to treat symptoms.
A doctor I spoke with recalled a patient with apparent signs of adult onset diabetes. A nurse practitioner, he said, would have prescribed medicine to produce insulin. But the patient mentioned having had a gallstone attack. Connecting the two events, the doctor realized that a gallstone had become lodged in her pancreatic duct, “burning out” her pancreas and keeping her from producing insulin. No insulin medication would undo that. That detective work, he said, drew on what is taught in medical schools.
Dr. Jane Fitch, president of the American Society of Anesthesiologists, began as a nurse anesthetist but later earned a medical degree. Speaking out against nurses practicing independently, she looks back on being a nurse and says, “I didn’t know what I didn’t know.” Nursing organizations suffer from that over-confidence.
These groups point to studies purporting that patients do as well with a nurse practitioner as with a primary care doctor. But most studies are sponsored by nursing organizations or lack scientific rigor. The often touted study by lead author Mary Mundinger only lasted six months, so most patients saw their “provider” only once, and there’s no way to tell who fared better in the longer term. “Far from convincing” is how an editorial in the Journal of the American Medical Association described that study. Longer-term studies are needed.
One good outcome of the December 2014 federal budget deal is that doctors’ groups convinced Congress to delay the VA’s plan to rely on nurse practitioners (including nurse anesthetists in the operating room) until the risks could be assessed. If only state lawmakers would show the same concern for patient safety.
Betsy McCaughey, Ph.D., is chairman of the Committee to Reduce Infection Deaths and a senior fellow at the London Center for Policy Research.