Thursday, April 03, 2008

What Influences Advocacy for "Doctor Nurses?"

We have posted many times on the external forces battering primary care physicians (family physicians, general internists, and general pediatricians) in the US. Whenever new fervor for cost cutting arises, the tendency seems to be to call them in as the usual suspects. Thus, primary care doctors have seen their reimbursement lag inflation (see our post here and a post from DB's Medical Rants here), while they are subject to an ever increasing bureaucratic burden aimed at decreasing their supposedly wasteful and overly expensive practices. No wonder fewer and fewer physicians are going into primary care, and more are leaving. They can make much more with less hassle and a "better lifestyle" in other specialties, especially those based on procedures. Yet it is hard to see how our health care system can work with ever fewer, and ultimately no primary care doctors. Health care systems in other countries, which may produce results as good as or better than the US, are much more focused on and supportive of primary care. When no American has his or her own personal physician, who will be able to diagnose their less than obvious problems? Who will be able to manage their inter-related chronic diseases?

Instead of making primary care practice a more workable proposition, however, the current fad is to find other ways to do primary care that do not really involve primary care doctors. For example, an article in the Wall Street Journal addressed the idea of making nurse practitioners get doctorates (but not medical degrees, heaven forfend).

As the shortage of primary-care physicians mounts, the nursing profession is offering a possible solution: the 'doctor nurse.'

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

One wonders how much nurses will learn from this two year program which might be the shortest doctoral program ever proposed. Primary care physicians, of course, take four years (two mainly classroom, two mainly clinical) to get their degree, and then spend three or more years in post-graduate house-staff clinical training.

Nonetheless, Mundinger seems to imply all that extra training does no good.

A study led by Columbia's Dr. Mundinger and published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary-care physicians.

Mundinger partially bases her advocacy of the "Doctor Nurse" on the assumption that nothing can or will be done to make it more possible for doctors to practice effectively in the primary care arena.

Dr. Mundinger, of Columbia, says the primary aim of the DNP is not to usurp the role of the physician, but to deal with the fact that there simply won't be enough of them to care for patients with increasingly complex care needs. As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

In addition to training in diagnostic and treatment skills, doctors of nursing practice can have hospital admitting privileges, coordinate care among specialists, help patients with preventive care, evaluate their social and family situations, and manage complex illnesses such as diabetes and heart disease, says Dr. Mundinger, who has been leading the effort behind the National Board of Medical Examiners' planned certification exam.

Note Dr Mundinger's acceptance (the use of the word "fact" above) that the decline of primary care physicians is inevitable. How well two years of training beyond the bachelors degree will prepare these advanced practice nurses to do what used to be done by doctors with at least seven years of training neither Dr Munginger or the article addressed.

In my humble opinion, the solution of our health care problems will not be the "delivery" of "primary care" by people with substantially less training than primary care physicians. The blog DB's Medical Rants has been thoughtfully addressing some of the misconceptions that may underlie this bad idea. One, which DB attributed to "suits" who control but do not really understand health care, is that primary care is basically simple, limited to care of minor acute illnesses and routine prevention based on guidelines. This ignores all the complexity and ambiguity and uncertainty that taking care of the whole patient entails. (See in particular the idea that primary care doctors must deal with the concept of the "long tail.") Primary care really involves dealing with less than obvious, often obscure diagnoses, coordinating management of complex and interrelated chronic illnesses, whose prognoses and response to therapy are difficult to predict, and dealing with intricate biopsychosocial issues. It may be harder and harder for primary care doctors to do these tasks, given that they are not paid to do many of their components, and they are besieged by conflicting and often nonsensical bureaucratic demands. But "doctor nurses" with much less training will find them even harder.

So why does this bad idea continue to gain traction? It may be that the influences behind its advocacy are not as straightforward as they seem. Let us revisit the WSJ article above, and particularly the advocacy of "doctor nurses" by Mary Mundinger.

That name should, in fact, sound familiar to Health Care Renewal readers. While Dr Mundinger is the Dean of the School of Nursing of Columbia University, she has some part-time gigs. In particular, she is on the board of directors of UnitedHealth Group , the large for-profit managed care organization and health insurer. As a director, she is supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] For that loyalty, by 2007 she had received (per the company's 2007 proxy) rights to acquire 345,930 shares of UnitedHealth, and in 2006 was paid $73,750 in cash and stock options valued at $412,575. That level of compensation might inspire some loyalty.

Presumably, it is in the interest of UnitedHealth to hold down what it pays for primary care. In fact, the company, like most other managed care organizations and health insurers, has gone along with the physician payment scheme used by Medicare, and de facto controlled by the shadowy RBRVS Update Committee, which has minimized payments to primary care, but paid for procedures much more lavishly (see post here). Thus Dr Mundinger's advocacy for primary care furnished by "doctor nurses," who would be less well trained and paid than primary care doctors, might serve UnitedHealth Group's interests.

But Dr Mundinger's loyalties seem even more complex than that. She has been known as a particular supporter of the former CEO of UnitedHealth, Dr William McGuire. A 2006 Pulitzer Prize winning article in the Wall Street Journal quoted her thus, "We're so lucky to have Bill. He's brilliant."

In fact, we posted often (see these posts here, here, and here from 2006 with links backward) about the hugely lavish compensation afforded to the Dr McGuire, and how this remuneration stood in stark contrast to the stated mission of UnitedHealth Group:

UnitedHealth Group is a diversified health and well-being company dedicated to making the health care system work better. The company directs its resources into designing products, providing services and applying technologies that:
- Improve access to health and well-being services;
- Simplify the health care experience;
- Promote quality; and,
- Make health care more affordable.
Controversy has swirled over the timing of huge stock option grants given to Dr McGuire (see post here), leading to his resignation in October, 2006 (see post here). More recently, McGuire agreed to pay back some of those options, although that would reportedly leave him with more than $800 million worth of options (see post here).

Dr Mundinger's support of McGuire lead two advisory firms, Institutional Shareholder Services (ISS) Inc. and Proxy Governance Inc, to suggest that institutional investors not vote for Mundinger in the 2006 election for UnitedHealth board members (see post here.) Thus, she seems better known for her personal loyalty to the CEO whom she was supposed to supervise than her unyielding loyalty to UnitedHealth Group's stockholders.

To make things even more complex, Mundinger also is a member of the boards of directors of Gentiva Health Services, and Cell Therapeutics Inc. Gentiva Health Services provides home care services. Cell Therapeutics Inc is a biotechnology company that develops cancer treatments. Per its 2008 proxy statement, Dr Mundinger received $127,531 in total compensation from Gentiva Health Services in 2007, and has received options to purchase 10,090 shares of its stock. Per its 2007 proxy statement, Dr Mundinger received $92,865 in total compensation from Cell Therapeutics Inc in 2006, and has received options to purchase 23,750 shares of its stock. Thus she has reason to have unyielding loyalty to the stockholders of these two companies. However, these companies' interests, to maximize profits from home care services, and to maximize profits from cancer treatments, conflict with the interests of the UnitedHealth Group to minimize what it spends paying for these services and treatments.

So trying to figure out the influences behind Dr Mundinger's prominent advocacy of "doctor nurses" is well nigh impossible. Dr Mundinger has an amazingly complex set of conflicts of interest. So where do her interests lie? - Improving clinical care and promoting clinical science and teaching (the academic mission of her nursing school)? Increasing UnitedHealth Group's profits by decreasing its payments for health care? Increasing Gentiva Health Services' profits by increasing the payments it gets for home health services? Increasing Cell Therapeutics Inc's profits by increasing what it gets paid for cancer therapies?

And that is, as we have said before, the curse of conflicts of interest in health care. Conflicts lead to confused thought, speech, and action. One cannot tell what interests lie behind the speech and actions of the conflicted. So health care policy advocacy by the conflicted, rather than leading to better health care for all, just leaves us in a fog of doubt and confusion.

But financial ties to various industries, regardless of the conflicts they produce, fuel the imperial pretensions of their academic health care institutions' leadership (see post here). So the universities and their leaders will not give up their conflicts without quite a fight. But the confusion about clinical care, about research, about health policy that swirls out of the ever more pervasive web of conflicts in health care means it's time for that fight to start.


Anonymous said...


Anonymous said...

Just wanted to clarify something you stated above, the 2 year doctoral program is assuming the prerequisite of an already attained master's degree. Thus, the doctoral portion is 2 years and the master's portion is anywhere from 2 - 3 years.

I do appreciate the fact that you didn't bash NPs as most of your blogging colleagues chose to do when this topic has arisen.

Adam Greene said...


*very* nice post Dr. Poses.

I almost cringe to ask such a basic question, but can such a muddle of conflicts ever be untangled while many of the health-care providers are for-profit entities? As long as the possibility of significant financial gains is on the table, the pressure to maximize ones personal fortunes will be incredibly strong.


Anonymous said...

Is it possible that part of the problem is brought on by doctors themselves. I've known several doctor wannabes; they have grades that should admit them to medical school . . . but the number of wannabes far exceeds the number of "openings". In other words, to maintain professional prestige and exclusivity, medical schools artifically limit access to hosts of applicants.

Sadly, primary care physicians are 'sinking' to 'employee' status. And if we compare the medical profession to other BigBusinesses, the modus operandi always begins by eroding the foundation. Consider Enron or Bear Stearns: those who do the real 'grunt' work are the first to be laid off (or overworked because others have been terminated).

Don't primary care physicians have some power? If "specialists" have no one to refer specialty patients--how will they get business? Depend on patient self-diagnosis and patient referral?

Anonymous said...

We have this from the WSJ Health Blog:

April 1, 2008, 10:54 am
Doctors Lobby Against Medicare Payment Cuts
Posted by Sarah Rubenstein

Meanwhile, research from the Medicare Payment Advisory Commission and others hasn’t uncovered shortages of doctors for Medicare patients, according to the Hill.

Last year, the American Medical Association spent $22 million on lobbying, its biggest sum ever, the Hill reports. Only three groups outspent it: the U.S. Chamber of Commerce, General Electric and, you guessed it, the Pharmaceutical Research and Manufacturers of America.

I think it is important to note that the AMA represents a small minority of doctors and has opened it's membership to those with an interest in medical issues, i.e., device and drug companies and drug reps.

We also need to consider the financial conflicts doctor's themselves promote, such as: Is pharma provided food as part of the office compensation package?

Does pharma provide all of the office supplies?

Do patients have to walk around a drug rep to get to an exam room?

Do patients wait while the doctor talks with a drug rep?

Do you run a branded drug only practice, thus eliminating the low income or ill patient that would benefit from generics?

Does the doctor envy the income and life style of a drug rep?

The financial conflicts have certainly become so rampant in medicine as to be, at times, impossible to separate from what may be considered normal business practices. The nurse Ph.D. certainly offers an attractive alternative to insurance companies, hospitals and others looking for a different employee model. ( While the focus is different, we have people with eight years of medical training, usually interrupted with work experience.)

One issue dealt with in the articles is the existing NP/PA's and future educational requirements. In our state we went to a Pharma, Ph.D.. The universities were quick to come on board as this increased the number of graduate students. The result has been a shortage of retail pharmacist, an increase in salary requirements for new hires, and over qualification. These folks would be great in a hospital, but are ill suited standing behind a counter talking to old ladies.

While I do not know if the nurse Ph.D. will help elevate the low reimbursements and increasing stress of private practitioners I do see any number of financial drivers promoting this program. For better or worse, the results will be a very different practice model than the one we have today.

Steve Lucas

Anonymous said...

Doctoral education in nursing isn't new - it's been around since the early part of the twentieth century. While I can't speak to Mary Mundinger's specific conflicts of interest -a ctual and potnetial, I can speak to doctoral education in nursing, which is decidedly NOT driven by managed care corporations or the insurance industry. Nor is it designed to conflate nursing with medical practice. That argument is spurious, and is insulting to nurses and nursing, as well as being dishonest and misleading to the public.

Like anyone with a doctorate who is involved in seeing patients, the provider always identifies himself and herself by role and credential (nurse, pharmacist, psychologist, social worker, etc.). That's the law in all states across all disciplines.

Don't worry - there are so few nurses educated at the doctoral level across programs and clinical specialties, that soon the nursing shortage will tip over the edge, nursing will fail catastrophically to meet the public's need, and we can go bqck to the stone age of health care without having to drop one of those pesky mushroom cloud bombs.

What this story has shown is that whenver the thin veneer of physician civility is scratched, a tribal, turf-driven, gender biased monster emerges. Heaven forbid that physicians ever recognize nursing as an autonomous, contributing helping profession that benefits patients and society. Nope - the assumptions that nurses are physician wanna-bes, are being uppity and not obedient and demonstrating the required obsequiousness and deference to their physician betters come spewing forth.

Fine - provide all of the nursing care, meet or exceed all of the desired patient outcomes, and meet or exceed nursing standards of care and practice. Do it on a 24/7 basis and in all nursing practice settings (don't forget home visits to the projects and to rural areas without electricity and running water or sanitation). And make sure you meet all of the state licensure requirement for nursing.

Then we'll talk.

Anonymous said...


You make any number of valid points. If we define "primary care," as SteveSC does in a comment at DB's, as the initial point of interaction between patient and medical care then we see nurses are already doing this job very well, in very demanding circumstances. Everyone should also be aware of the unrealistic demands and resulting high burnout rate in the nursing profession.

I unfortunately saw ego overcome good sense in a social setting where a brand new MD was very concerned with everyone's academic background. Introduced to a woman, old enough to be his mother, he questioned her Ph D. When told in was in nursing he, in a dismissive tone, said "Oh, you are a nurse." Needless to say, we were not impressed. She had just returned from a former Soviet satellite country after securing, arranging training, and having installed some imaging equipment we seem to worship in this country.

Steve Lucas

Unknown said...

"What this story has shown is that whenever the thin veneer of physician civility is scratched, a tribal, turf-driven, gender biased monster emerges. Heaven forbid that physicians ever recognize nursing as an autonomous, contributing helping profession."

In my opinion, nurses should work under the supervision of doctors. They should not be autonomous. I'm a breast cancer survivor, I just had to change my oncologist because she is so busy as medical director of her facility and bigwig in breast cancer research that she relies excessively on a nurse practitioner. The care I was receiving suffered as a result.

My personal experience with nurses, including nurse practitioners, is that they are in no way shape or form equivalent to doctors. They don't know as much, and most of them wouldn't have been able to get into medical school. Wouldn't have had the grades or the smarts. They generally don't keep up with medical research.

The idea that Roy's post was fueled by some kind of gender bias is absurd.

I'm a lawyer and we have people called legal assistants. Legal assistants work under the supervision of lawyers. They are not allowed to practice law.

Primary care is not simple. It is complex and difficult.

I don't know what the solution is to the fact that medical students aren't going into primary care, but replacing them with nurses (with I don't care what kind of degree) isn't it.

Marilyn Mann

Anonymous said...

To my medical colleagues,

I have been a nurse practitioner for over 25 years and I do not consider myself a physician nor have I ever wanted to be one. I am a nurse - not a physician "wanna-be"! While NPs are as capable as many MDs of providing primary care, we bring to healthcare something unique. We bring to a "medical encounter" the strong foundation of nursing - traditionally known as the caring profession. We give our patients something that they must feel is lacking in traditional primary care medicine, as evidenced by them seeking us out and staying with us as their PCP.

I ask you to please not judge nursing, NPs or DNPs based on the words of Mary Mundinger. She does not speak for the entire nursing profession nor has she ever. In my opinion, you make some very valid points regarding her "conflicts of interest" BUT....

We are facing a major healthcare crisis with the elderly population expected to double if not triple by 2030. The demand for PCPs will overwhelm the supply. Instead of engaging in a turf war between medicine and nursing, we should be collaborating with each other to find a solution. Let's keep the dialogue open.

Carolyn Auerhahn, EdD, GNP-BC, NP-C, FAANP

Anonymous said...

@Steve Lucas:

Thank you for your perspective. Interestingly, this debate doesn't surface in rural and other underserved areas. It appears where there is perceived income and turf incursion on private practice.

Nurses are routinely insulted - just look at the next comment by an uninformed, but highly educated patient, Marilyn Mann. By contrast, it would be unthinkable to insult medicine or physicians and expect that to be tolerated. Nor would any reasonable nurse do that out of hand.

We must begin to examine why it is not only is tolerated and considered socially acceptable to impugn the education, professional legitimacy and societal contributions of nurses and nursing, but we (as members of the nursing profession) must begin to reject that and to demand professional respect.

Marilyn Mann is correct, however, in her statement, "nurse practitioners, is that they are in no way shape or form equivalent to doctors". Nursing is a distinct profession. It doesn't aim to be subservient to medicine nor does it aim to substitute for medicine.

This is the current accepted definition of nursing:
"Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.

(Nursing’s Social Policy Statement, Second Edition, 2003, p. 6 & Nursing: Scope and Standards of Practice, 2004, p. 7)"

Ms. Mann alludes to some of the critical issues in nursing: multiple educational routes to licensure and practice, and the lack of nursing researchers and faculty holding joint appointments in both research/academic and clinical practice settings. Nursing faculty earn less than the most novice two year associate degree new graduate in many markets, and so the supply of faculty is incredibly tight.

Ms. Mann spoke ignorantly and in a biased manner when she generalized her own experience with a single nurse to the entire profession, and she demonstrated contempt for all nurses with: "They don't know as much, and most of them wouldn't have been able to get into medical school. Wouldn't have had the grades or the smarts. They generally don't keep up with medical research."

Isn't that interesting - I turned down medical school for nursing. (grin) I'm not the only one, and there is a fair number of people who have crossed over professions, finding one a better fit for their individual interests and strengths. (disclosure - I'm a Case Western Reserve University and Columbia University grad, and I am a doctorally educated nurse in nursing administration. I am not a nurse practitioner.) My physician colleagues in healthcare quality and patient safety have both mentored me and have been supported in return as we collectively address some of the system issues which are critical to patient safety and tolerable practice conditions for physicians and nurses.

The more we understand about each other's profession's interests, needs and limitations, the better we can allocate available resources in innovative ways to achieve outcomes that mutually benefit our professions and our members, while improving patient safety and lowering morbidity and mortality rates.

As Dr. Auerhahn commented, medicine and nursing work best when they work collaboratively and synergistically. It's critical that the dialogue be open, safe and based on trust and mutual respect.

That's what was woefully absent in the WSJ story, and it undermines the public's trust in nursing, the physicians' relationship with nursing and nurses' trust in medicine's members to act in an ethical and respectful manner.

Anonymous said...

If it makes you feel any better, annie, I sometimes have a hard time getting adequate care from doctors also. And in my own profession, there are plenty of attorneys I wouldn't send my worst enemy to.

I have nothing against nurses. My objection is to nurses as any kind of substitute for physicians. In my opinion, they should always be supervised by physicians.

I'm sure there are some nurses who could have gone to med school, although I doubt they are a very high percentage. But they didn't, and they don't have training that is equivalent to doctors.

Marilyn Mann

Anonymous said...

Good Lord- don’t you all get tired of the mud-slinging? Personally, I want to take care of my patients the best way I know how (which is pretty darn fine, by the way) and teach my students to the best of my ability (which is also pretty darn fine, if I do say so myself).
Of course, anyone that takes a nanosecond to actually look at the facts about this topic will realize that the Doctor of Nursing Practice (DNP) will take 2 years to complete only for those applicants who already have a Master’s degree and are already trained as an NP. With some slight variations, those who are starting from a baccalaureate degree in nursing will take 4 years of full-time study to get their DNP. I’ll bet the person who started this topic is not a complete idiot, so he probably knows this fact, but wants to, nonetheless, make inaccurate and inflammatory comments and then sit back and watch the brouhaha that ensues. Of course, I guess it is possible that he is a complete idiot and is just spouting off with whatever comes into his head about this topic. Lord knows, he has plenty of colleagues who do just that. What’s scary is to consider that he might practice medicine in the same manner- just spouting off whatever comes into his head, not collecting the appropriate data to come up with a differential diagnosis and then formulate a reasoned assessment and plan. Of course, my responses are all based on an inaccurate and inflammatory posting on a blog, so, who knows, I could be wrong and this person might be doctor of the year.
Although I may disagree with Dr. Mundinger's position on this topic, I find it appalling that the first thing you want to do is attack her ethics and ascribe her actions to some murky all-about-the-money scheme. I continue to be amazed at how threatened medicine seems to be about the rise of the NP. Ya, Ya, I know, your only interest in this is about the patient. Uh-huh. That stance is so transparent that lots of folks (not nurses) who write far better than I do have already responded to that claim and shown how self-serving it really is.
I'm sorry to hear of the other respondent’s breast cancer and I do sincerely pray she is receiving the treatment she wants and needs. That said, WHEN are the uninformed going to stop basing their entire argument regarding a topic on anecdotal evidence? When are supposedly educated people going to stop throwing around unproven negative comments and actually base their responses on fact? There are TONS of good data supporting the notion that NPs provide equivalent care, and for some aspects of that care, superior to what a physician provides. And yes, before it gets said, the bulk of such research is done by interprofessional teams of researchers that include representatives from medicine and nursing. Of course, we’re all seeing how actual facts don’t stand in the way of those who want to bash nursing and NP in particular, but please, it’s getting really tired.
Yeah, maybe this respondent interacted with an incompetent NP. God KNOWS, I have interacted with a LOT of incompetent MDs, both before and after becoming an NP. As in any field, there are incompetent practitioners out there. As a profession, nursing has a mechanism in place for dealing with such practitioners and, it seems to me, we employ those mechanisms with a great deal more vigor than my medicine colleagues do when confronted by an incompetent physician. Funny though, when it’s the physician that’s incompetent, you don’t hear the inflammatory, inaccurate and hurtful comments that we in nursing have been subjected to the past few days.
ENOUGH already. Go review the literature, both medical and nursing, review the curriculum of current Master’s programs that are preparing NP’s, and review proposed DNP curriculums. Until you do that SHUT-UP and stop embarrassing yourself. You’re comments about nursing, NPs, and the DNP degrees are about as helpful as would be my comments about the law and the structures and processes in place there.
PS. Just to end with my own anecdotal story. When I did my NP training at the University of California- San Francisco in 1997, one of my preceptors in internal medicine was Dr. Paul Volberding, easily recognized as a leading expert on the clinical management of HIV disease and a widely respected researcher with an internationally supported program of research.
I will never forget the first day of my clinical practicum on internal medicine. We were both a few minutes early to start rounds and, of course, he was curious who I was and what I was doing there. When I told him I was an NP student, he had a lot to say. In essence, Dr. Volberding said he thought NP’s had an important contribution to make to this country’s healthcare and that he was very supportive of NP practice. He actually went on to say that the NPs he had been exposed to had really impressed him with their nursing background, their growing medical knowledge, and their clinical acumen. He ended with saying - and I will never forget it- that he would prefer to have an NP specializing in HIV care managing his patients, rather than a family practice or internal medicine physician. True story.

Unknown said...

The issue of health care on this blog needs to move to the top and look at why health care costs are so high-until that is done, talking about whether the health care field should use Nurse Practitioners can't be seen in perspective.

As I've said elsewhere the main reason for high costs and the deterioration of quality are two subjects that are intertwined. Over-utilization of highly paid professionals is a sub set of the problem; a skilled nurse practitioner could run routine diagnostics and perform basic exams as well as a Cardiac specialist, to give but a single example, on a new patient or a returning patient who is exhibiting signs of a developing cardiac condition that would require further examination.

The subject seems to be, what level of expertise does one require and if more expertise is needed, will the patient get that? If professionals work in well coordinated teams, (which is more the problem than what the above article lets on), then the skill level, once it's above an acceptable lower level, (which the Nurse Practitioner example above would have) is not the real issue.

In short, the real concern, is:

Are medical professionals, health care plans and patients prepared to work together so that information regarding a patient's medical condition flows seamlessly around the system from provider to supplier to insurance companies. So far, Americans have not been able to focus on this issue. For that reason, we pay huge costs for the tremendous inefficiencies that result on the one extreme from too little information or too much time spent in duplicating information the patient has already given downstream in the information flow.

Anonymous said...

I do not know whether my former oncologist's NP was more or less competent than the average NP. My main point was that the onc was apparently too busy to take care of her patients properly, so relied excessively (IMO) on the NP. None of my other doctors have ever used an NP in this way, and I would be curious to know how common this is.

I see no reason why Dr. Poses should not point out Munsinger's COIs. After all, that is one of the main topics of this blog.


Roy M. Poses MD said...

Its interesting that any reference to nurse practitioners or advanced practice nursing on this blog seems to bring out emotional and often angry commentary.

"Annie" said I "insulted" all of nursing, not just advanced practice nursing, and accused me of gender bias. She later accused another commentator of "impugning" the whole nursing profession. How that relates to her call for "dialogue [that is] ... open, safe and based on trust and mutual respect," I can't figure out.

My post, of course, was not about the nursing profession as a whole, and not about gender.

"TR" accused me of making "inaccurate and inflammatory" comments, apparently based on my assumption that to get the Doctor of Nursing Practice degree only requires two years of training after the bachelors degree. If that is not true, I stand corrected. But this was not explained in the WSJ article, and it was the WSJ article I was commenting on.

Assuming "TR" was right about that, there is obviously still a substantial difference in the amount of training required to practice as a DNP (4 years post-baccaulaureate) compared to that required to practice as a primary care MD (7 years post-baccaulaureate.)

"TR" further insulted my ability to practice medicine, "What’s scary is to consider that he might practice medicine in the same manner- just spouting off whatever comes into his head...."

That accusation was obviously baseless.

Meanwhile, "TR" ridiculed the notion that Mary Mundinger's position as a director of UnitedHealth had any relevance to her advocacy of "doctor nurses." According to "TR," that was just a reference to a "murky all about the money scheme." Maybe "TR" should read about the nature of the allegiance a director of a public for-profit company is supposed to have, and then try to argue that a responsibility to maximize the profits of the shareholders of UnitedHealth would have no influence on one's position advocating for primary care providers whom UnitedHealth would have to pay less than primary care physicians.

Finally, "TR" just told me to "shut up."

Both "TR" and "Annie" ought to actually read my posts, and perhaps some other material on this blog before commenting. My point in this post was obviously not to bash nursing, but to note that a prominent spokeswoman for one particular concept of advanced practice nursing has an obvious and major conflict of interest that might influence her advocacy, one which she does not seem quick to disclose.

We welcome commentators who have substantive disagreements with what we post. Commentators who fling insults, or employ the last resort of the school-yard, instructing those who disagree with them to "shut up," show themselves as unable to advance more reasoned arguments.

Anonymous said...

Dr. Poses,
I have read all the posts in this blog and can honestly say alot of the comments are bound in each individuals passion for their chosen field of work. Each of us take care of patients because we love the work we do. Each of us care for patients because the work and the rewards we get far exceed anything else we could imagine doing. I am an oncology nurse practitioner who is highly regarded by both my physician partner and my patients. I find the collaborative relationship with my physician partner has enhanced our practice and has improved outcomes for our patients. My wish is that we can come together in collaboration to provide better quality of life for our patients and ourselves by joining hands and respecting each other for knowledge, comittment, and experience.
Catherine Bishop, N.P.

Anonymous said...

Catherine speaks for many of us in her statement. All nurse practitioners work collaboratively with physicians to provide care. Consults are always done as needed. As pointed out earlier, one should do research into our curriculums and clinical training before passing judgement on what we are capable of providing. The insuation that nurses "can't get into medical school" is pretty pathetic coming from a lawyer is all I can say. I know quite a few physicians who wish they had gone to school to be nurse practitioners!

Mary Mundinger, on the other hand, certainly is NOT the selected spokeswoman for nurses or nurse practitioners, despite her prominent position at a prestigious school.

Nurse practitioners have been providing primary care for years and years now, without a doctorate, and are being utilized more and more in specialty practice. Research shows that patients are highly satifisfied with nurse practitioner care. They are not "substitutes" for a physician, but are providers within their own right. All NPs collaborate with physicians. If you're not getting care from a physician when you need it, you should be addressing that with your physician to find out why. That's not an NP problem.

Sadly, this WSJ article just shows how much more nursing needs to do to educate the public on just who we are, even as we strive within our own profession to define it.

The court is still out on the DNP. The profession is far from agreeing on this as the "standard" of education for entry into NP practice.

Anonymous said...

It is very difficult to get into medical school. I, personally, never could have done it. I stand by my statement that the majority of nurses could not have gotten into medical school.


Anonymous said...

And your statement that the majority of nurses could not have gotten into medical school is based on???
Solid, empirical evidence? No? Consensus statement by experts in the field? No? Just your opinion? Oh, OK, your opinion. Jeez...

Unknown said...

First off, this blog serves a great purpose. Honestly, it saddens me to see COI issues present in healthcare, particularly if it involves ANY health care provider. I believe our health care system is broken and ill-conceived regulations are in place to “help” prevent COI issues (i.e. Stark laws). The unfortunately reality is that our healthcare crisis cannot be attributed to this single Dean of Nursing. It is also unfortunate that the good Dr. Mundinger attempts to do for nursing is somehow negated by her apparent impropriety.

The question is, does not one nurse a health care make? Our great nation can only hope not. Unfortunately, Dr. Mundinger does not appear any different from other business men and women sitting on various boards or involved in the upper echelons of their perspective fields. Fortunately, for health research, authors are required to disclose any potential conflicts; this is a good first step. Now the issue possibly moves towards the Deans of nursing, medicine and other health sciences. Possibly, this is the next step.

I do not wish to come across angry in presenting my point of view; instead, I would like to teach. I was glad to see Dr. Poses concede that he may have erred in his understanding of prerequisite requirement for the DNP program. The WSJ is just one article with the intent of providing information; possibly, it was taken out of context in its attempt to provide another point of view. Ultimately, I have great respect for the WSJ and I am equally aware that it is in the business of writing about business, not health care. As consumers, we should admire the WSJ’s journalist fervor in presenting varying points of view, but understand any article pertaining to health care should demand the requisite fact checking.

I cannot speak for another, but TR’s accusation was potentially grounded in the issue of a tacit approach. I’m neither a physician nor a journalist, but if I were presenting myself to the public as an expert by posting on a blog dedicated to transparency in healthcare, I would certainly check my sources. It seems no detail was spared on Dr. Mundinger. No one should get their healthcare facts from the media, especially those educated in the health sciences.

A quick Google search produced the admissions requirement for the Columbia DNP program. Frankly, it is no different from the other programs developed across the nation. See:

I believe Dr. Poses “unintended” barb that spurred “emotional” and “angry commentary” was incited by the utilizing of words such as “current fad” to fix primary care is “making nurse practitioners get doctorates (but not medical degrees…” with the qualitative jab of “heaven forfend.” Statements such as these do come across as contrived in pomp with the suggestive propriety that medicine is somehow better than nursing, or that nursing is not good enough to hold doctorates in their perspective fields. This is particularly true since NPs have been providing exceptional primary care much to the chagrin of physicians for most of the last 4 decades.

Honestly, the premise behind a doctorate of nursing practice has little to do with the profession of physicians. It truly is about nursing. Nursing does not have a clandestine agenda to provide second rate medical service. Instead, nurses are attempting to provide top rate nursing service. In fact, there is a fiery debate about the cost and burden of this degree and the consequence it may have on well-intended NPs who wish to make a contribution to healthcare. In fact, in the name of quality, nursing should work from the bottom up and demand a bachelor degree for entry into practice rather than continuing with associate degree programs. However, this should now preclude the profession from providing (not demanding) the opportunity for NPs to obtain greater education for doing a job done well in the first place. Marilyn’s experience the notable exception.

In the interest of full disclosure: I am a NP. My bachelor degree in nursing included two and one half years of didactic/clinical course work dedicated to clinical practice. Additionally, my two year (didactic/clinic) master degree did require “at least” one year of clinical practice prior to admission; I had more. Admittedly, since graduating Emory the program has been condensed and compressed to a year and a half, or one calendar year – I don’t know how. From my perspective, I have had 4 ½ years of proper health-related education plus my clinical experience, albeit less than that of a physician. However, we are not comparing apples to oranges…we were discussing impropriety in healthcare. Now that is something worthy of “heaven forfend.”

I bet all us well educated individuals could come up with a solution.

R Fox

Anonymous said...

Ladies and Gentlemen,
Let's get back to basics. First off, the DNP degree did not come about because of some perceived conspiracy by United Health Care. It is filling a long time gap in nursing education that needed filling, namely a practice based doctorate. Medicine has the MD and the DO; Pharmacy has the PharmD; Physical Therapy has the DPT. You get the idea. Previous to the DNP, nurses could only get a research based PHD at the majority of schools and unless that nurse was interested in research, what was the point? With the introduction of the DNP, nurses like myself who are interested in practice and not research have an avenue to a higher degree and will become the leaders in the practice in our profession.

Nursing is a unique profession. We are not physician wannabe's. Nurses possess knowledge of medicine, which overlaps that of our physician colleagues,but we also possess our own unique body of knowledge which exists nowhere else. Nursing is much more holistic in its approach, addressing the mind-body-spirit connections that are inherent in true health. We strive to be genuinely present for our patients, meeting them where they are within their own context, taking into account how their family, culture, spiritual beliefs, and community will effect their health practices and recovery from disease. As a result, a nurse's focus is more on health promotion, disease prevention, and teaching, rather than solely on the treatment of disease or injury. Oh, and by the way, we also treat disease and injury.

I will always concede that physicians have a superior technical grasp of medical science. That is why they have a medical doctorate (MD). Most physicians soon learn however, that nurses have a superior intuitive grasp of what is going on with a patient. When you are the sickest of the sick in my critical care unit, who do you think is making the crucial moment to moment decisions that are keeping you alive? The physicians? The physician intensivist is there for 10 minutes on his rounds and the other 23 hours and 50 minutes per day, there is just the nurse and the patient. These same physicians, who I respect, admire, and consult with on a daily basis due to the aforementioned superior technical knowledge of medical science, usually, if not always ask ME what I think the patient needs.

This brings me to another point. Someone mentioned 4 year physician residencies in making their point about nursing's training being inferior to that of physicians. Spending 13 hours a day at the bedside of patients without a physician in sight for the last 13 years has been MY residency and I will stack that up against any medical residency for depth and breadth of experience.

Will nursing ever displace medicine in primary care? Of course not. It is a ridiculous notion. Physicians are a wealth of knowledge that we nurses will always consult with and refer patients to when necessary. We bring a different perspective that has been proven to enhance patient outcomes and satisfaction. Nurses are not assistants, subordinates, or physician wannabe's. We are professionals.

Anonymous said...

As a medical resident who has had medical problems and interacted with nurses attempting to perform what has traditionally been the role of physicians, I can tell you that what I got for my money was talking the talk but not being able to walk the walk. In other words nurses may be able to fool the average patient into thinking they are getting medical care but in reality what they will get is a dangerous sham.

Anonymous said...

So, You Want To Be A Doctor……

Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year on average, others have concluded may be the national average and factors in payers both of a private and public nature.
Yet considering the additional attention of shortages of students in some medical schools as well, as conceived by others, one could posit hat this professional vocation that has been one viewed in the not so distant past in the U.S. as one with great esteem and respect may not be desired as a vocation by many, that requires commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of thier lifespan. Such reasons for this paradigm shift may include:
Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction and financial security of one of the many and newly created health care systems These regional and nationally created systems are typically composed of numerous hospitals and clinics under combined ownership- frequently of a private nature that is not dependent upon their beliefs as it is perhaps on their profit motives and intentions. Yet their approach and etiology of their views regarding the restoration of the health of others are usually similar with such mergers of multiple medical facilities, which are presently preferred to save costs, it has been said, and therefore these systems have not been protested by a largely uninformed public.
Conversely and in addition, this system of increasing popularity is not necessarily a desired method to practice medicine as a primary care physician, often stated by them as members of their employer that has the power to limit and dictate how they practice medicine. This is because, among other reasons, such doctors have largely unexpected and unanticipated limitations regarding their patients’ heath provided by them. This is further aggravated by possible and unreasonable expectations of their employer, such as mandating that doctors they employ are required to see as many patients as theycan in a day, and there have been cases of physicians being fired by a health care system- along with financial rewards for seeing more patients a day than what is determined as average visits by others. Such requirements likely and potentially affect or alter the clinical judgment determined by physicians employed in what may be viewed as authoritarian employers, which would limit the medical care they provide to their patients, as well as the quality of this care. Also, such health care systems may have their own managed health care system that may be determined by factors not in the best interest of the patients of doctors employed by the health care system.
The primary etiology and stimulus for a doctor to practice medicine in this way is due to their frequent inability to provide and employ ancillary staff, combined with the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently.
Malpractice laws and premiums, which is determined in large part on a state level, are an issue with those required to have this adverse aspect of their professions. Also, these premiums become more expensive for doctors, depending on the perceived risk of their chosen specialty. For example, the premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. Plantiffs win about 25 percent of the time on average a half a million dollars. 95 percent of these cases are settled out of court.
In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine, which basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. Because if a doctor practices medicine in such a way, it typically involves what may be considered as unnecessary diagnostic testing for their patients to rule out what may be unlikely disease states of their patients’ medical conditions. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients.
Such restrictions and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility on a societal level. It seems that this perception and vocation that now is greatly misperceived due possibly to being deformed by others who may have profit as their motive for the health care they may dictate to doctors they may employ in some way, which often and likely is in conflict with their motives as doctors and how they wish to deliver needed health care to others. This may be why this medical profession may no longer be viewed as distinct from other vocations, in large part, as it seems that presently the profession of a doctor has been reduced to one dependent on the financial stability and growth of its employer, which may alter how the doctors perceive what is expected of them as well, which may affect the importance of how they view their profession, as it has been said that overall, doctors are somewhat understandably more cynical and demoralized, which may be replacing the pride they historically have viewed their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.
Further complicating and vexing to these restrictions is the usual financial state of the individual physician, as theynormally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed, it has been estimated, along with this debt amount presently is about 5 times higher than it was only a few decades ago.
Conversely, there are some who believe that doctors in the U.S. are over-paid and are compared with some corporate monster, who behaves based upon the premise of greed. In spite of how they are judged, physicians are likely not absent of financial concerns- which may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a physician, as others are more dependent on their judgment.

It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable it is also and potentially unfortunate for the health of the public in the future, and the nature normally associated with the medical profession which could deter ideal medical care for others
There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.
Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession in relation to how their vocation is viewed by others and based on limited judgment and analysis. Yet citizens overall should determine what sort of health care they desire, and it seems that often they fail to voice this right as a citizen.
For perhaps Primary Care Physicians in particular, the medical profession and those who provide medical care clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.
“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero
Dan Abshear
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

Anonymous said...

The arrogance of the NP movement to
the DNP is amazing. A cursory review of the content of the extra "doctoral" training reveals it to be more of the same study that makes up the NP master's degree. There is no quality control on entering students or routes for this process.

As a general internist in Virginia in need of some assistance with a heavy load of patient's at a State facility, I have had occassion to review a few NP CV(s). Those going for the DNP have created pompous self-important descriptions of themselves practicing medicine and its various subspecialties as if they were attending physicians themselves. The lie that the objective of the DNP is not to replace primary care docs is just that- and like the Nazis observed- the BIGGER THE LIE, THE MORE FOOLS THERE ARE TO BELIEVE IT. The ambition and arrogance of the NPs is blitheringly obvious to all of us.