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.

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Natalie Newman MD

Dr. Natalie Newman is a residency trained, board­certified emergency physician who has been practicing for nearly 24 years. In 1991, she graduated from California State University in Sacramento, California with a degree in Biological Sciences. She then attended medical school at Case Western Reserve University in Cleveland, Ohio on an Army scholarship. As a graduating senior, Dr. Newman was presented with the Marjorie M. and Henry F. Saunders award for her compassionate care of patients within the family structure. After her graduation in 1995, she was accepted into the Emergency Medicine Residency at North Shore University Hospital in Manhasset, New York. Upon her graduation in 1999, Dr. Newman entered active duty service with the U.S. Army. Her first assignment was at Womack Army Medical Center in Fort Bragg, North Carolina. During her stint in the Army, Dr. Newman was deployed to Bosnia­Herzegovina(formerly Yugoslavia) where she was Chief of the Emergency Department at Eagle Base in Tuzla, Bosnia. She had the honor of serving under the command of Colonel Rhonda Cornum(now a retired brigadier general), a urologist, pilot and former prisoner­of­war during the Persian Gulf War. While in Bosnia, and as the only American female physician in the Balkans at that time, Dr. Newman was assigned as the personal physician for Queen Noor of Jordan during a humanitarian visit to a local hospital in Bosnia. After her return home to the U.S., she was promoted to Major and completed the rest of her Army service at Fort Bragg. Dr. Newman subsequently returned home to California where she continues to practice as a traveling physician and participates in multiple speaking engagements about the values of education, of which she is passionate. She is also a member of Physicians for Patient Protection, a patient and physician advocacy organization. 

  7 comments for “A HISTORY OF NPPs–A PERSONAL VIEW

  1. Ed Mathes
    July 21, 2019 at 6:19 pm

    “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.”

    I’m going to parrot Mike Sharma, OTP is not independent practice. I’m one of those “seasoned” PAs, 40 years in practice. Our profession was built on the foundation principle of collaborative, team practice. Laws written 20, 30, 40 years ago have not been updated. They are wedded to the concept of “supervised” practice, often requiring a rigid agreement that, in excruciating detail, describes what the PA can and can’t do, codifying the concept the physician is ultimately responsible for any wrong-doing on the PA’s part.

    OTP removes that formal agreement, removes the “designated” physician, allowing the Physician/PA team and/or their facility to decide appropriate duties and levels of responsibility. As the PA gains experience, responsibilities can be expanded (or contracted) to meet practice and professional needs without the added administrative burden of changing the practice agreement.

    Additionally, OTP makes the individual PA responsible for their own actions (or lack thereof), removing some liability risk for the physician.

    I’m an old-timer. I’ve been around Medicine for 50 of my 65 years….started as volunteer EMT, progressed to combat medic, then on to PA school. All along the way I benefited from the encouragement and support of many, many physicians (and nurse!). I do not condone, nor do I support, the concept of “independent practice” for PAs or NPs. I’ve been around too long and seen to much to want that level of responsibility. It is comforting to know that, even after 4 decades, I can approach any of the doctors I work with and ask anything without any hint of recrimination. This is why I support OTP. I hope y’all take some time and learn more about it.

    • Natalie Newman
      July 21, 2019 at 7:30 pm

      First, thank you for your service. I am a former Army physician and some of the best PAs with whom I have ever worked were trained in the Army. I also happen to personally believe that PAs are a much better fit for the emergency department. Although many legislators dismiss it, being trained in the medical model makes a difference.

      I did state that this commentary is my view only. I have read about OTP. It would be foolish for me to make reference to it had I not. I agree, the concept is not necessarily a bad one. It is in the actual execution of the program that I am ambivalent. I suspect that some PAs will attempt to use OTP as a stepping stone towards independent practice as there is nothing in place to prevent it. I also believe that the development of the Doctorate of Medical Science(DMS) degree that some PAs have obtained is/was to be used exactly the way the Doctorate of Nursing Practice has been used by the NPs, to deceive the public into believing they are physicians. In two states, Tennessee and Washington, PAs did just that. Introduced a bill that would allow PAs with a DMS degree and a subjective amount of years/hours of primary care practice to become independent primary care practitioners. Fortunately, both bills failed because it was unsupported by the majority of PAs and physicians. How do I know that OTP might not be yet another way to circumvent the actual process of becoming a physician? The reality is I don’t.

      It certainly doesn’t help when I see statements like this from AAPA website promoting OTP: “Eliminating the requirement for an agreement with a specific physician will make it easier for PAs to practice in medically underserved communities where there are not enough physicians (and in some cases, no physicians) to care for patients. PAs would also be able to provide volunteer medical services and respond to disasters and emergencies – situations in which physicians might not be available or willing to enter into agreements with PAs, but immediate care is needed.” THIS IS DESCRIBING INDEPENDENT PRACTICE. The terminology is similar to that used by NPs to advance unsupervised practice. Although the goal appears altruistic, in reality, it does not limit PAs from working wherever they choose or from opening their own clinics with limited to no supervision. And in that model, where is the “collaboration”? That may not be your intent, but you certainly don’t speak for all of your colleagues. There is also language that suggests there will be changes in how billing is done. Again, I am concerned that particular aspect will ultimately lead to a quest for pay parity. Just as with NPs, once PAs achieve independence and pay parity, there will be no distinction between physicians and NPs/PAs, other than the number of years of training required for each profession. For these reasons(and others not stated), I do not support OTP as it is written. That is my stance.

      https://www.aapa.org/advocacy-central/optimal-team-practice/
      http://www.capitol.tn.gov/Bills/110/Bill/HB0696.pdf
      https://app.leg.wa.gov/documents/billdocs/2017-18/Htm/Bills/House%20Bills/1771.htm

  2. Mike Sharma
    July 21, 2019 at 7:24 am

    Saying that physician assistants’ push for optimal team practice (OTP) is “similar” to the full practice authority and responsibility that is being sought by other professions weakens what is otherwise an interesting article. I think that physicians have enough education and appreciation for nuance that even a basic understanding of OTP would reveal important distinctions. Long story short, PAs want to practice in teams with physicians. We want to do it in ways that promote shared knowledge and reduce onerous, one-size-fits-none regulations forced down from the state level that could not hope to encompass all the different practice settings and sizes in which physicians and PAs work together.

    https://www.aapa.org/advocacy-central/optimal-team-practice/

    • Natalie Newman
      July 21, 2019 at 7:32 pm

      Answered. Please see above.

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  3. Sean William Ochsenbein
    July 21, 2019 at 12:09 am

    How do we contact Dr. Natalie Newman? Would like some help from her on a ACEP resolution this year.

    Thanks, Sean
    [email protected]

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    • Natalie Newman
      July 21, 2019 at 7:34 pm

      I am no longer a member of ACEP.

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  4. Rob
    July 20, 2019 at 9:55 am

    Well written from this former NP now MD.

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