Monday, February 12, 2018

The New Medicine

This morning I spoke with a nurse who is in the University of Massachusetts Lowell nurse practitioner program. She is 25 years old and has been working on a ward at a community hospital and says, "I can't see doing that at age 40. I'm exhausted when I get home at night."

She is taking course work at the university and expects to have her NP certification in two years, 2020.
She got her BA in nursing in 2017.
I asked where she will do her clinical training and she smiled and said, "That's the problem. I have to arrange for my own."
"What? You mean with a doctor?"
"Or with another nurse practitioner."
"But how do you know if they are any good?"
"That's what I'd like to know," she said.
The clinical rotation covers 6-9 months, sometimes a year, but it is not clear how many hours a day this means. As a working floor nurse working 8 hour shifts, presumably the clinical rotation will not be 8 hour days.

At one of our clinics, all the primary care doctors quit and the manager, a thirty something woman with a MBA told me that really would not be a problem. They can always find nurse practitioners or physicians assistance to see patients. The doctor who signs off on their patients does not have to be on the premises, in fact will be about 10 miles away seeing his own patients.

I considered how I learned about patient care. It's true, I did not have much direct training dealing with patients who were not critically ill. We had a weekly outpatient clinic which most of my fellow residents thought a waste of time because the patients really didn't have much wrong with them, as opposed to the patients we saw in the hospital who often had several things wrong with them, each competing to see who could kill the patient first. I didn't mind the clinic, though. I got to see the patients I had seen in the hospital in follow up and it was amazing how healthy and normal they looked. Gratifying really. Some of those folks we wondered why we were working so hard to save, they looked so damaged, but then, six months later they looked like normal human beings.

Being exposed to people who turned out to have leukemia, or colon cancer or lung cancer or serious vascular disease or heart attacks or new onset diabetes for four years taught me a lot about how innocent sounding symptoms could be the harbinger of serious underlying illness.

It also made me respect influenza, strep pharyngitis and pneumonia, which occasionally landed a patient in the hospital where sometimes we could not save them.

How a nurse with 6 months of "shadowing" another nurse practitioner could step into the world with that kind of preparation, I could l only imagine.
She will look like a doctor, with a white lab coat, a stethoscope around her neck and many of her patients will not actually understand she is not an MD but she will know.

Fact is, she will be "cost effective" for the MBA who manages the clinic: Her salary will make those Excel spread sheets for the clinic's income and overhead look good.


  1. Mad Dog,
    What's infuriating is the motivation behind the push to replace doctors with NP's and PA's. It's one thing if this was taking place in rural outposts where there is a shortage of physicians, but their proliferation in areas where the supply of doctors is adequate once again illustrates what's driving US healthcare. Certainly not patient care or treatment quality- but profits. Unfortunately, there are far too many voters out there so busy worrying about the government coming for their AR-15's, that they are failing to notice the erosion of the medical system right under their noses..but that's another subject...

  2. M,
    Well, it may be the same subject. AR-15's are what people think they understand. Just gimme one of those and we'll all be safe from school shootings, home invasions and Islamic radical terrorism.
    But many folks do not know a Nurse Practitioner from an MD from a chiropractor from a naturopath.
    Until there is enough reporting on all this, I suspect we'll get what we deserve when it comes to medical care, and I can guarantee you only one thing: the quality of what we get, what we are getting now, what we are going to get when the profit motive is the controlling force in American medical care is going to be only a shadow of what medical care in Europe currently is.
    Every Republican always begins with, "Oh, you don't want to give up the best medical health care system in the world for some government controlled system!"
    Sorry to tell you, but the best health care system in the world is a government controlled system.