Nurse Practitioners and the “Art of Medicine”
By the “art” of medicine I mean the ability to reason beyond rote memorization, strict standards of care, and “cook book” style medical practice. By “art” I do not mean the tendency to apply diagnostic and therapeutic medical practice in a freewheeling way that is not based on reasonable evidence (this is quackery). The art of medicine is something that is very difficult to teach in a didactic course. It’s something that is often learned in a practical setting from a mentor who pours out their years of experience onto the pupil. This goes on for 3 or more years and hundreds of 36-48 hour shifts during post-doctoral training for physicians. Yet this type of practical training is usually squeezed into a few months for nurse practitioners. One hopes that this does not make a difference in patient care. Experience tells me otherwise.
Recently I saw a patient who had been seen by a nurse practitioner (NP) a few months prior. The patient was an advanced octogenarian who had not been feeling well with recent loose stools, nausea, and weakness. I reviewed his medication list and found that the NP had prescribed metformin for this patient’s diabetes. Metformin is an excellent medication for diabetics since it is cost effective and does not have as much risk of weight gain and hypoglycemia (low blood sugar) as other medications. But it does have side effects, the most common being nausea, vomiting, and diarrhea, and a rare risk of lactic acidosis which has a very high fatality rate.
Although not an absolute contraindication, advanced age is associated with increased risk of metformin associated lactic acidosis because of age and diabetes related decreases in kidney function and the increased incidence of other co-morbidities including heart failure. Sudden illnesses in the elderly such as infection can quickly lead to dehydration which can lead in turn to kidney failure and induce metformin associated lactic acidosis.
I asked the NP about this issue and the apparent solution was to be argumentative. First the NP suggested that we periodically check a lactic acid level. Not only is this of no practical value since lactic acidosis can set in and lead to death in a period of hours but there is no evidence that periodic monitoring of renal function and lactate levels reduces this risk. Then the NP’s plan B was to claim that metformin is safer in the elderly than other drugs called sulfonylureas because it won’t cause dangerously low blood sugar. But studies (Arch Intern Med 1997 Aug 11-25 and JAMA 1998 Jan 14) have found the risk of hypoglycemia from these medications in the elderly to be very low (16.6 episodes/1000 person-years) and have concluded that elderly patients can be safely treated with these medications.
Then there are the practical aspects of avoiding harmful effects. Though the incidence and hence risk of hypoglycemia with sulfonylureas is higher than the risk of lactic acidosis with metformin, the symptoms of low blood sugar are much more apparent and can result in quick and effective treatment while lactic acidosis often presents as vague and non-specific symptoms leading to treatment delay. And there is no evidence that early intervention in metformin associated lactic acidosis can reduce the risk of death. And while lactic acidosis is mostly an idiosyncratic and difficult to predict condition, hypoglycemic risk can be effectively ameliorated by starting treatment with low doses and increasing the dose slowly while educating the patient and the caregivers about the signs and symptoms of hypoglycemia and ways to avoid it and treat it.
But the NP didn’t understand the biggest issue of all. Does the patient’s diabetes even need to be treated?
As it turns out, the patient’s measure of diabetic severity, the Hba1c test, was very low at 6.3% (normal being less than 6%) and was checked several months prior when the patient was not taking any diabetic medication. So the question remains, why should we treat this patient with medication?
There are two reasons why we treat diabetes. The first is to reduce the near term effects of hyperglycemia (high blood glucose) that can lead to increased urination, increased thirst, dehydration, weakness, blurred vision, ketoacidosis, etc. The second reason is to reduce the long term risks from untreated diabetes such as heart disease, stroke, blindness, peripheral vascular disease, and kidney damage. Not only did this patient NOT have any symptoms of diabetes in his untreated state but given his advanced age and other co-morbid conditions, his chances of developing a complication or symptom of diabetes in its untreated state are minuscule compared to his risk of developing complications from a side effect of diabetic medications!
It is this subtle point that is the “art” of medical practice. It’s the ability to compile all the data and treatment standards and throw in rationality in understanding risk and benefit to determine the importance of knowing when NOT to treat the patient as much as knowing when and how to treat.
Had this issue been about a rare side effect of a very uncommonly used medication, I would have understood but this issue involved one of the MOST commonly prescribed medications with a very well known risk for an extremely common medical condition.
In the very least, this NP is a malpractice lawyer’s dream. If you are going to treat a patient with a potentially deadly medication when there are safer alternatives around then prudence would dictate that you do so for a good reason and document this reason as well as the fact that you informed the patient of the risks and what to look out for and how to avoid the risks (if possible). This NP didn’t document any of this and lawyers like nothing more than an uninformed patient.
So far, studies have not shown any difference in the quality of care or outcomes of care between NPs and MDs/DOs. But many of these studies were done at academic centers where the training and preparation of the NPs and physicians is generally excellent rather then in the usual outpatient setting where the quality of NP training and delivery of care can be much more variable and less controlled. And though the odds of a serious reaction in this patient are low, multiply this by hundreds of patients and the odds that there will be a serious medication reaction increase dramatically.
I don’t know how to teach the “art” of medicine but it seems reasonable to assume that this “art” will be significantly lacking for health care providers who are either inadequately trained and experienced and/or don’t have the time to apply anything more than a “cookie cutter approach” to medical practice. As primary care dies a slow death in this country, both of these factors are going to become more common. NPs will have an ever increasing role in primary care since very few physicians are entering this field after training and most NPs will be employed by corporations and private clinics and under ever increasing pressure to see as many patients as possible.
So what can be done to have doctors stop chasing the money of specialties and stay in general practice? The primary care practitioner shortage has been a long-time coming who do you think should fill the gap?
Ahh, the million dollar question. We have a great opportunity to improve all around care, quality of care, and decrease over-utilization of health care resources all at the same time. Enhance and change the way we compensate primary care docs. Give them a sharp raise and lower volume in the form of capped payments per patient (the same way concierge practices do) and some mechanism to reward/punish PCPs based on utilization. More on this in later posts.
NP’s and PA’s are not perfect, but can be utilized. Maybe there just needs to be limitations on certain types of patients they can see? As everyone knows most learning comes once you are working in the real world. Those professions do not have the same experience as MD’s, but there need to be some kind of working relationship that can be positive. Mostly for the patients
I think the practical take home point here is that the quality of health care is going to be directly impacted by trends in increased patient loads and increasing numbers of mid-level providers who have less training and less experience being utilized to fill in the massive gaps in primary care provider shortages. This is all a direct result of the low and pathetic way that we reimburse our primary care providers.
But I don’t believe that this is an adversarial relationship (yet). There is still way too much demand and too few providers to go around. Rather then being critical of their care quality, I believe that most clinics, physicians, or businesses that employ mid-levels are way more concerned about their ability too see as many patients as possible in a given time frame and too keep the patients happy.
I’m sorry you had this experience, but I don’t think you should base your view of a group of providers on one bad apple. I am a nurse practitioner and could point to physician errors and faulty logic just as easily. However, I understand that there is good and bad in every profession. The research speaks for itself.
I encourage you to engage with more nurse practitioners as it seems the majority of us enjoy a collaborative relationship with our physician colleagues. There are more than enough patients to go around. We can achieve the most good when we work together.
I don’t base my view of NPs based on this one experience. I raise a question of concern based on this experience.
I have worked with many excellent NPs. I have worked with many (far too many) bad MDs. The concern is about increasing patient loads on health care providers who – by design – have less training and experience.
The solution? Likely a redesign of primary care but one that certainly will include mid-levels as a critical component.
NP’s will be required to get their PhDs instead of only a Masters degree starting in 2015, I wonder if that will help with the experience levels?
As a practicing NP in a highly specialized endocrinology office, I would like to point out that prior to recieving my NP degree I worked for 24 years in clinical settings such as: pediatric intensive care, cardiovascular intensive care, neonatal intensive care, medical surgical, and gerontology. Most NP’s have extensive experience in a clinical setting prior to ever entering a master’s program. MD’s do indeed recieve a highly extensive education and have a vast amount of knowledge that with the right attitude could work collaboratively with NP’s in providing great quality of care.
Would you be in favor of requiring NP training programs to have their students go through much longer clinical rotations if they don’t have extensive experience prior to entering an NP program?
Just would like to clarify an error posted by David. The degree proposed for NPs to obtain by 2015 is NOT a PhD, but rather a DNP. A PhD is research focused and a DNP is PRACTICE focused. For the purposes of this discussion, this is a distinction that must be clear. The DNP will require double the number of clinical hours as the current requirement and includes much more content (too much to go into here…check the ACNP website for details). Whether this will result in better or “stronger” NPs remains to be seen.
Very interesting article and replies, btw!
So, if an ANP already can bill on par with MDs/DOs, what would be the advantage of DNP degree? Independent practice (ANPs can already do this in many states)? To make double what MDs/DOs do? Mostly for academia?
I’m sorry you had this experience, but I don’t think you should base your view of a group of providers on one bad apple. I am a nurse practitioner and could point to physician errors and faulty logic just as easily. However, I understand that there is good and bad in every profession. The research speaks for itself.
I encourage you to engage with more nurse practitioners as it seems the majority of us enjoy a collaborative relationship with our physician colleagues. There are more than enough patients to go around. We can achieve the most good when we work together.
Bruce, it’s interesting to see how people read more in certain articles then there really is. I never based by opinion on an entire profession based on one example. That would be fallacy by sample bias. I simply used this example to raise a question, to which I still don’t have an answer.
I see what you are saying in your article. There is no dispute about the amount of education and training MD’s and DO’s go through. I just recently graduated, prior to that I have been exposed to MD’s who like NP’s and those who don’t. It’s their preference. Personally, I like the idea of being an NP to work with MD’s. I have a lot of respect for their knowledge and enjoy picking their brains. What I am getting from this is your concern about the care patients will be getting if healthcare turns to more NP’s as the one described in your article. Unfortunately, this could be a problem but the same goes for MD’s as well. I know that I am constantly asking questions and I can certainly handle constructive criticism (and ask for it). You can never be sure of what you are getting in a healthcare provider. As an NP I’m there to help not hinder. We have a common goal, patient care and to provide the best. We need to work together and reap the benefits.
I think the take home message here is to KNOW WHAT YOUR DOING AND WHY! With the increased demand in patient load verses care time, this can be difficult but you shouldn’t treat unless you know what and why and look at the whole picture.
Thank you for the article, it will certainly make me take an extra minute.