A HISTORY OF NPPs–A PERSONAL VIEW

THE PARADIGM SHIFT: ONE DOCTOR’S VIEWPOINT

Many of us who have practiced for years are well aware of the value nurse practitioners(NPs) and physician assistants(PAs) have brought to the medical team. There was a time when there was a mutual respect amongst all within that physician-led health care team. Every role was well-defined and each person was skilled in their respective positions, allowing the group to function as a well-oiled machine. The patients benefited and U.S. medicine was number one in the world. Then corporatized medicine entered the mix….and the downfall began. These businessmen(and women) decided that patients would become a commodity, a dollar sign. As with most businesses, their primary goal was to increase profits and keep their investors happy. Physicians became a burden because they were too expensive. But to simply remove physicians from the equation would not have boded well in a country like America, so the change had to be strategic and insidious. We had to be devalued. The physicians, PAs and NPs became “providers”–the lack of distinction was intentional. The C-suite began setting the stage for physicians’ removal as team leaders. They began cutting back the number of physicians and increasing the non-physician provider(NPP) pool–they were cheaper to hire. Up until then, it was possible to see every single patient with the NPP. That changed. The docs could not keep up with the volume, so they had to trust that the NPP would do what was appropriate and involve them when they deemed it necessary. And they usually did, they were seasoned professionals. Then a paradigm shift began to occur….the seasoned, highly qualified NPPs began leaving. Their replacements were not of the same caliber. There was no vetting of these individuals by the facilities hiring them since the doc, and not the facility, owned the liability as they were expected to supervise them. The cultivation of these practitioners by those of the same ilk who had more experience became non-existent; they were left to their own devices with no leadership of their own. Physicians, who were trained under a medical model, were expected to train nurses, who were trained in a nursing model, how to practice as advanced nurses using a medical model. And then supervise them. Absurd concept but we did it anyway, with no idea of what we were doing. PAs, having been trained under a medical model as well, transitioned easier.

Medical professionals, including physicians, were complicit in this paradigm shift also. Physicians, nurses and PAs entering administrative positions lost sight of what it was to be on the front lines of medicine(and nursing). The physician-led model of medicine became cumbersome and inconvenient. Quantity rather than quality of care became the status quo. Physicians on the ground, disenchanted, disillusioned and disgusted by their treatment and overburdened by unreasonable expectations, relinquished the close supervision of NPPs that had previously existed. They used them as flunkies. The NPPs, never having experienced this type of autonomy on a large scale, rose to the occasion because they had no choice. Although they did not possess the medical foundation of knowledge needed to practice on their own, they nonetheless began “managing” the patients. Over time, they began to believe they could actually practice the same as physicians and really didn’t need the supervision. Hell, medicine isn’t that hard after all. They didn’t know what they didn’t know. The seasoned professionals preceding them did, but they were gone. There was no more guidance. There were no more teachers. We see that manifested today in the explosion of preceptor recruiting organizations. It is unprecedented.

Adding to the complexity of the situation, Medicare stopped funding residencies. No one expected the cap would be permanent. They expedited the physician shortage. Plenty of medical students, not enough residencies. So these potential physicians, foreign and domestic, were relegated to working at Starbucks, Target or Wal-Mart, while their MD/DO/MBBS degrees sat on the shelf collecting dust. The American Association of Nurse Practitioners(AANP) took advantage of the lull and came up with the brilliant idea of filling this physician gap with nurses. No action or opinion on the nursing shortage which is much worse than the physician shortage. And they still remain mum on the subject. Nevertheless, credibility matters in America; the public will not accept nurses as doctors. To counteract that perception, the AANP decided to mandate 100% of their members obtain a Doctorate of Nursing Practice(DNP) degree. Surely one must question just how valuable an education is one receiving if 100% of the practitioners are able to obtain the degree? It didn’t matter that the DNP is not a clinical or scientific degree, it still allowed the graduate to refer to himself as “Doctor”. It didn’t matter that promoting oneself as a “Doctor” with this degree in a clinical/medical setting implies, in our culture, that one is a physician and is illegal in many states. Some NPs do it anyway. The AANP insists that they are practicing advanced nursing, ironically using the same definition which is used to define the practice of medicine. And they shamelessly continue to advance the idea of “independent” practice, knowing that there are NP degree mills graduating unqualified, unprepared and undereducated students. Degree mills with 100% acceptance rates, the only requirement for entrance being that one possess a pulse and a checkbook. With no standardization or regulation of NP education, no one universal accrediting body for these myriads of programs, no one national standardized exam to test for competency….the AANP continues to move forward on promoting the unsupervised practice of ALL NPs. It is irresponsible and downright criminal. The PAs have a similar model, Optimal Team Practice(OTP). It is my belief that PAs, in general, would not be seeking independence were they not being pushed out of their positions by nurses untrained in medicine. It is about career survival. I understand the sentiment.

Nevertheless, no one should be allowed to practice medicine unless supervised by those trained and educated in it. Yet here we are, discussing what to me should be blatantly obvious. Physicians have a responsibility to shift the paradigm back to where the patient is the number one priority. We cannot allow individuals with business degrees to dictate the story and define/demean our value to the medical profession. It is our place to write the book, not theirs. Primum non nocere…First do no harm. By turning our collective heads and looking the other way, legislators, physicians, nursing leadership, media conglomerates and laypeople remain complicit in propagating the harm being done to our patients. Physicians must continue our advocacy for our patients….and for ourselves. Because we know that education matters. It is indeed a matter of life and death.