Living Across State Lines as a Family Nurse Practitioner: The Koolaid is the Same

This is not a blog about bashing the hubris of Mr. Cody Yochum. He’s probably a great guy just taking advantage of opportunities that avail themselves to him. He doesn’t know what he doesn’t know. I can’t write about his experience in nursing. I can only write about mine as a former RN for 15 years then NP for 8 before becoming an MD. This is more about the ‘kool aid’:

 “Even in the ICU, NP care is equal to or better than what is provided by physicians. I do central lines, arterial lines, intubations —even hemodialysis lines. I’m able to do procedures that attending physicians can’t.”

How often do we see this sort of sentiment these days? Heck, when I was a new nurse practitioner I believed it too. Got my first prescription pad, and that was confirmation that I was the bomb. I even thought I could park on the physician’s parking spaces. I thought I was equal. I didn’t know the difference. I didn’t know what I didn’t know. The notion of equality and even superiority was the ‘koolaid’ being fed even at early stages in my nursing career. Afterall, I could ‘do’ everything the physicians could do in my field. What I was missing was threefold: (a) understanding the notion that ‘doing’ things does not a physician make, (b) understanding of the vast difference in educational preparation between the NP and MD, and (c) comparing nursing with medicine is like comparing apples to oranges – a fallacy. 

‘Doing’ things as a marker of physician equality is a farce. However, throughout my nursing career, it is rampant. I mean, certified nursing assistants (CNAs) can ‘do’ many things a licensed practical nurse (LPN) can ‘do’. Are they equal or superior? No, just different. The LPNs resent the notion of equality. The LPN’s can ‘do’ many things an associate degree RNs (ADN) can ‘do.’ Are they equal or superior? No, just different. The ADNs reject and resent the notion. The ADNs can ‘do’ many things a bachelors prepared RN (BSN) can ‘do.’ Are they equal or superior? No, just different. The BSNs reject and resent the notion. The BSN’s often have years more bedside clinical experience to the nurse practitioner (NP). Are they equal or superior? No, just different. The NP’s resent and reject this notion. The NP’s can ‘do’ many of the same tasks and MD/DO and do. Are they equal or superior? No, just different. MD/DOs reject and resent this notion. MD/DOs can save lives with almost devine care. Are they equal or superior to God? No, just different. Get the point? What one ‘does’ or can ‘do’ is not a marker of equality or superiority. 

In terms of educational preparation, CNAs are different from LPNs; LPNs are different from ADNs; ADNs are different from BSNs; BSN’s are different from masters prepared nurses (MSNs/NP/CRNAs etc); MSNs are different from doctor of nursing practice (DNP); DNP is different from MD/DO. There is neither inferiority, equality, nor superiority amongst degree types. Just different with different roles and functions and educational preparation. Let me illustrate from my own experience. My MSN curriculum was 650 clinical hours in the program. One semester of ‘advanced pathophysiology,’ called physiological concepts for nursing. In this semester course, week 3 was cardiovascular (CVS).  Required reading was 3 chapters from Copstead, L-E. C., & Banasik, J. L. (2005). Pathophysiology (3rd. Ed.), St. Louis, MO: Elsevier Saunders. In summary, 1 week on the CVS with 3 chapters. Now my medical school curriculum was about 4-5000 clinical hours. The pre-clinical 1st & 2nd years were foundational sciences and system based modules with one system module on the cardiovascular system alone. Week 1 alone was on chest pain. Required week 1 reading was: Gray’s Anatomy for Students, Chapter 3 Thorax, Heart section; Guyton & Hall Medical Physiology, 5 chapters; Robbins and Cotran Pathologic Basis of Disease, Ch 12 (The heart); Rang and Dale’s Pharmacology, Ch 21 (The heart); Goldman’s Cecil Medicine, 3 chapters. In summary, an entire 8 week module on the CVS with 11 chapters per week. 

In terms of comparing nursing to the practice of medicine. This is a fallacy. I recently wrote about this in another Authentic Medicine blog (3). I won’t rehash that again here, but suffice to say, can you really compare apples to oranges?

Have a great day

REFERENCES:

  1. https://news.illinoisstate.edu/2019/10/living-across-state-lines-as-a-family-nurse-practitioner/?fbclid=IwAR1tUwTEf3Bz45R81HkU_ou15X1MJVuuXYBSIcQFFX7otUAJCcODrCrmVFE
  2. https://nursing.illinoisstate.edu/100-years/The-Flame-2018-19_web.pdf
  3. https://authenticmedicine.com/the-apples-oranges-fallacy-comparing-hospitalist-resident-to-hospitalist-midlevel-practitioner-team-performance-with-the-banana-factor/
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Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams 

  6 comments for “Living Across State Lines as a Family Nurse Practitioner: The Koolaid is the Same

  1. November 15, 2019 at 7:43 pm

    Thank you for the responses. To briefly address the hyperbole:

    Why a Doctoral Level PA Degree? Read this and please notice that nowhere it states that a Doctoral Degree in Medical Science prepares anyone to replace a physician.

    https://www.lynchburg.edu/academics/college-of-health-sciences/physician-assistant-medicine/doctor-of-medical-science/program-goals-and-outcomes/

    Dr. Newman: What will you tell a physician who wants a PA that they do not want to supervise?

    Nurse Practitioners in many states require no physician supervision. You’d think this would make them the least desirable option when deciding on a non-physician “provider.” However, the opposite is true. Physicians, overwhelmingly, do not want to supervise anyone. If you want to supervise a PA or an NP, and when you rebuild your career, you are welcome to supervise anyone you want.

    The fact that you want PAs to be supervised and you want every other physician to believe what you want them to believe tells a lot about you.

    Pat: I call everyone my colleage and they refer to me the same. From the C-suite to housekeeping and anyone in between. I don’t know if you work in healthcare but when’s the last time you thanked a housekeeper for keeping the environment clean and sanitary so patients can heal. A little humility goes a long way.

    In conclusion, or until the next wave of zealots surface, PAs are not seeking independent practice. Anecdotes and hyperbole does not even prove that an independent PA, if they were seeking this, would be any less effective in doing what they do every single day working for somebody else.

    To address any concern just look at our NP colleagues. Many practice independently with no significant statistical increase in morbidity or mortality. NPs practice advanced nursing. PAs, like Physicians practice medicine.

    To all the skeptical physicians out there; I hear you. I hope you have great success. I will work with you to increase residency slots. We have similar interests and goals. This “beef” between PAs and group(s) like PPP and others are misguided.

    Till next time.

  2. November 12, 2019 at 6:28 pm

    I disagree with my colleague above, albeit partly. First and foremost, there is no alternative to the education and training of an American Physician. That being said, it does not mean a PA who has, for example, put in central lines and is proficient in doing so, cannot do this without “supervision.” The supervision requirement is a burden on the entire healthcare system. Again, this is complicated and fluid. Does every PA need no supervision? Absolutely not. Does every PA need to be supervised? Absolutely not. So to address this quandary there’s a movement to pass OTP or Optimal Team Practice. OTP is in line with what our Physician colleagues want for PAs. The Physician should not be legally responsible for the actions of a PA. The Physician, if he or she employs the PA should be able to decide on how the Physician wishes to supervise their PA. So why OTP? Because PAs, who are the only professionals, besides Physicians, educated and trained to practice medicine on the whole body are being forced out of opportunities because there’s another profession, who answers to another non-medical board, who has convinced their board to grant them independent practice. So instead of Physicians choosing their own, who they have to supervise, they would rather employ the professional who they do not have to supervise. Less work for the Physician. PAs are not pushing for parity with MDs, PAs are pushing for parity with what Physicians already allow non-medical providers to do!

    TL/DR: PAs want OTP. OTP makes the Physician the leader of the team. OTP does not demand independent practice for PAs but seeks to modernize how PAs practice by making the Physician the leader of the “team.”

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    • Douglas Farrago MD
      November 13, 2019 at 5:26 am

      We heard all this from the NPs. It’s a trojan horse. If I am wrong then why create this: https://www.lynchburg.edu/academics/college-of-health-sciences/physician-assistant-medicine/doctor-of-medical-science/

    • Natalie Newman, MD
      November 13, 2019 at 8:39 am

      Optimal Team Practice(OTP) does not recognize the physician as the team leader because there is no team leader. It is a free for all, much like the NP movement for unsupervised practice. The physician however, will remain a safety net for liability for everyone who wants to practice medicine without a medical license(see below). Although the law may not imply that the physician is responsible, a savvy lawyer can indeed make the physician liable. In a case that has a bad outcome as a result of negligence or malpractice by a PA/NP, all an attorney has to do is state that the individual PRESENT, possessing the most expertise in medicine(that would be the physician by training and education), had a responsibility to step in and address whatever the issue may be. Even if the physician had no idea the patient existed. And there is nothing to prevent the attorney from doing just that. A hospitalist in Missouri was sued after giving a curbside telephone consult to a NP with whom he had no professional relationship. Her patient died from sepsis after being sent home on his advice, based on information provided to him by the NP. The patient was unknown to him. Missouri is an unsupervised state, meaning the NP was supposedly “independent”. The NPs “collaborating” physician, who agreed with the hospitalist, was sued by the family also. Both physicians lost. The NP, the only one who had a relationship with the patient, had seen the patient and was responsible for her care, was dropped from the case.

      Any physician who thinks he/she is protected from liability by supporting OTP is a fool.

      “When a PA isn’t legally tethered to a physician, PA employers (health systems, hospitals, and group practices) can be more flexible in determining healthcare teams. This will allow them to more effectively meet patient needs. It will also 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 specific relationships with PAs, but immediate care is needed.”

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

    • Pat
      November 13, 2019 at 11:30 am

      If PA’s are “not pushing for parity,” then why do you refer to physicians as “colleagues?”

  3. Jesse Lee Belville,PA-C
    November 12, 2019 at 3:51 pm

    Thank You.
    I am a PA-C FOR 43 YEARS. I am not an NP or MD./DO.. I was trained in the medical model as are MDs/DOs. I am a PA-C. Under the Supervision of a Physician I do 70 to 90 % of what my Supervising Physician. I am a Supplement To , NOT a Replacement for the Physician. I improve access to care, and those who are more ill or complicated see the Physician,while I see his less complicated or Acute illness patients. This improves access to care , Quality and more timely appointments. Higher patient Satisfaction.
    Un fortunately the NURSING POWERS and PA POWERS are pushing for Parity..
    So Physician’s get political and protect your Turf.. Otherwise Nursing will be controling us all.

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