A Compendium of Anecdotal Evidence

Without beating the proverbial dead horse, it’s feeling important to lend my two cents to the topic of independent practice for advanced practice nurses. And before launching into the rhetoric that will inevitably inflame significant numbers of the readership, I will cushion the onslaught by describing my experience working alongside non-physician providers, during the entirety of my training and physicianhood, which is overwhelmingly positive. Frequently lost in the conversation is the sentiment of comeraderie and mutual appreciation of the unique contributions of non-physician providers to the health care team. I enjoy my physician and non-physician colleagues as my extended work family and as my personal friends. I have been personally moved by witnessing in my physician and non-physician colleagues strong spirits of advocacy, empathy, and many examples of going above and beyond the expected to provide excellent care. And I won’t get into the specifics of the lopsided trajectory of primary care physician shortages plus lobbying to non-medical lawmakers to “fill the gap” with nurses, citing biased research, not to mention the existence of the murky shadow world of nonclinicians acquiring graduate level nursing degrees online with inadequate (by most measures) clinical training, but when the idea of approximate equality between advanced nursing-level vs physician-level care became a movement, things began to take on the distinct flavor of unreality. 

As a proud generalist, I know enough about a lot, read a shit-ton about everything, manage a lot, and was rigorously trained in a specific, well-demarcated specialty, under the umbrella of meticulous supervision, for a continuous period of years. Via a steep learning curve, standing in front of the metaphorical fire-hydrant of knowledge and clinical experience, with the opportunity to wield my fledgling skills (and make mistakes) under the tight control of my supervisors and mentors for years before achieving the weighty responsibility of practicing independently, the probability that I do more good than harm has been well-established. Nothing less should be required of those claiming responsibility for the health and wellbeing of other human beings. 

Like myself, the best non-physician providers I have had the pleasure of working with know when they’ve reached their boundary of knowledge. The scariest and most potentially harming physicians and providers are those who don’t stay in their lanes and who can’t see the lines. There is a shortage of primary care physicians. We could be doing things to reverse this disturbing trend like incentivizing primary care for physicians by forgiving student debt, or making actual progress to reduce physician burnout. To the statement that advanced practice nurses should have autonomy to practice medicine without physician oversight I would agree, with the stipulation that they first pursue a medical degree. 

Just as I would not assume an advanced practice nurse should care for patients autonomously, I would also not claim that my training in cardiology makes me capable of fully managing all of my cardiac patients. Sure I manage atrial-fibrillation, CAD and CHF, very similarly to a cardiologist. Then there’s is the simple fact of math. Days, weeks, months, years more training spent focusing on the heart, hundreds, thousands more heart patients treated. Plus, who am I relying on when the STs elevate to cath and stent my patient? By the same token it’s the basic math of hours spent and requirements fulfilled of managing or at the very least correctly identifying in all their permutations those conditions that we dare not, that we cannot miss, that separates my management from that of someone with less schooling and less training. This is not a criticism. This is a fact. This falls under the purview of the oath on which we base our livelihoods and upon which we should base decisions on who should be independently managing patients: First, do no harm. There are those medical facts drilled into our brains, those conditions we saw and managed, manifesting in a multitude of presentations, again and again, in the middle of the night, in the middle of the day, to our surprise, to our dismay. Those things we’ve seen go great and those same things we’ve seen shit the bed in the most unexpected of ways. There is a knowledge base, a systematic approach to examining, to diagnosing, to thinking about medical problems that is unique to physicians in its rigorousness and in the prolonged time it takes to develop. 

There are myriad examples of management decisions that stand out in my mind because they detract from quality care and also are a lot less likely to have been made by a physician, that lend credence to the warnings against giving those with significantly fewer hours of learning and training the ability to manage patients without oversight. This is not to claim that there aren’t many times problems with the quality and/or quantity of that oversight, but that’s another battle for another day. When a clinician repeatedly orders a lupus anticoagulant antibody test to test for the presence of systemic lupus, and refers a patient to Rheumatology when it results mildly positive, this is a waste to the system. When a clinician orders both lumbar and sacral MRIs for nonradicular, atraumatic low back and tailbone pain of less than six weeks’ duration in a low-risk patient (both ultimately negative), this is a waste of several thousands of dollars to the system. When a patient suffers permanent nerve damage because her neck pain examination did not reveal the presence of significant R hand grip-strength weakness, because the provider examining her admittedly had never received training on how to perform a neurological exam, this is an unfortunate and unnecessary morbidity. When a malodorous, festering diabetic foot ulcer is treated with a routine referral to wound care, without imaging, or initiation of antibiotics, and the patient very narrowly avoids amputation but not a hospital admission or consequent prolonged rehabilitation, this is an avoidable and expensive strain on the system. When a patient reports having suffered symptoms of an obvious TIA, and the receiving provider has never seen this issue, never treated a patient with this issue, and is not aware that there is a well-established algorithm for its management that can be referenced within seconds, this is a potentially fatal problem, for that patient. There are way more tragic and costly examples than these. We are all fallible humans but ultimately the public deserves to be cared for by the most educated health professionals in the room. 

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Joanna Rulf, DO

Joanna Rulf, DO practices Family Medicine and Integrative Medicine in her second-home state of Maine. Originally from NJ, Joanna graduated from Rutgers University with a degree in English Literature, pursuing a career in the publishing industry in NYC before attending the University of New England College of Osteopathic Medicine from which she graduated in 2009. She completed residency in Family Medicine and fellowship in Integrative Medicine at Maine Medical Center in Portland, ME. During this time she also completed the fellowship curriculum from the University of Arizona Center for Integrative Medicine and received certification in Medical Acupuncture from the Helms Institute for Medical Acupuncture in Phoenix, AZ. Her practice blends the broad spectrum of rural primary care medicine with evidence-based management of a variety of conditions using Osteopathic Manipulative Medicine (OMM), acupuncture, and an array of wellness strategies. The mother of two young children, Joanna has journeyed hard on the quest for work/life balance, mental/physical wellness, and strives to help her patients (and colleagues!) do the same. 

  4 comments for “A Compendium of Anecdotal Evidence

  1. Steve
    July 1, 2020 at 4:01 pm

    I’m for any NP who has large breasts.

  2. Pat
    July 1, 2020 at 1:07 pm

    Well stated.

  3. Sarah
    July 1, 2020 at 9:42 am

    Thank you so much for so succinctly expressing what I and so many of my family physician colleagues are feeling and experiencing right now. There is no question that we have a serious shortage of primary care physicians. Filling these jobs with physician extenders is clearly not the answer for the reasons you stated.

  4. Gary Gaddis
    June 30, 2020 at 4:16 pm

    Here’s another take on this issue of unsupervised practice by non-physicians

    Despite our extensive training, physicians do make errors.

    Therefore, it must be but “magical thinking” to assert that our valued colleagues, who are NPs or PAs, and who have MUCH LESS training, both in the extent of coverage of the basic medical sciences, and in meaningfully supervised practice, could somehow provide equivalent care to that provided by medical doctors. Healthy, appropriate, supportive COLLABORATIVE relationships should define the best way forward. It’s not about CONTROL, it’s about QUALITY CONTROL.

    FURTHER
    One can gain an NP degree and self-arrange one’s clinical training environment from some of the “on-line” programs, and no one from the degree-granting institution ever visits the clinical site to verify the usefulness of and quality of the clinical training environment. And further, there is no equivalent to the Residency Review Committee to provide the necessary “third party oversight”.

    I enjoy reading Gabriel Garcia-Marquez’ “magical realism” fiction works, but please, don’t make me live in a clinical world where people believe in an equivalently creative, but unlikely “magical realism”. Let’s leave the “magical realism” to the realm of fiction, and rely on more FACT-BASED constructs in the real world!

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