I HAD A DREAM

Revisiting the dreams.

Nursing Stories

Mercury Sphygmomanometer

In preparation for moving I discover the darndest things as I unpack dusty boxes stored in the attic untouched for years. This time it’s a mercury sphygmomanometer, packed in its original carton along with a “limited warranty” card that should have been filled out within ten days of purchase. Looks like I didn’t even open the box but put the blood pressure machine away for the day I would open my independent practice.

That would have been in the early 80s after I became a gerontological NP

and

after I worked in Chicago with inner city, underserved elderly

and

after I became frustrated with the lack of resources and left to become an administrator of an HMO

and

after I knew I didn’t want to be in administration

and

after going back to work as a nurse practitioner once again

and

after moving to three different states

and

after finally…

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WHEN A NURSE IS AS GOOD AS A DOCTOR

I couldn’t pass up sharing this article in Consumer Reports about nurse practitioners and physician assistants especially since I just registered with my new provider, a nurse practitioner a week ago. She and a physician assistant cover for each other. Best of both worlds.

Check the comments, which are so positive.

When a nurse is as good as a doctor
Nurse practitioners and physician assistants can offer first-rate care
Published: July 14, 2015 08:00 AM BY ConsumerReports.org

Across the country, nondoctor health care professionals—usually nurse practitioners (NPs) and physician assistants (PAs)—are turning up in a range of medical settings. We see those so-called advanced practice providers most often in primary care and family medicine practices, but they also work as specialists in hospitals and retail clinics, and more. In rural areas, they may be the only health care providers who are regularly available.

Their ranks are growing fast. In the past 10 years, the number of licensed NPs in the U.S. has almost doubled to 205,000. Between 2003 and today, the number of certified PAs grew from about 43,500 to more than 102,000.

One major reason: Demand for doctors, especially family physicians and internists, is outstripping supply. The Association of American Medical Colleges expects a shortage of up to 31,100 primary care doctors and up to 63,700 other physicians by 2025.

Advanced practice practitioners can make up the shortfall. But can they give you the care you need? And how does the care compare with what you’d get from a doctor?
What they do, what they don’t
PAs and NPs are handling many tasks that were once the exclusive domain of doctors: They can write prescriptions in every state. In 21 states and the District of Columbia, NPs can practice autonomously. Some NPs and PAs substitute for residents at academic medical centers.

But there are differences between them and doctors. One distinction: What advanced practice practitioners are permitted by law to do can vary from state to state and even from hospital to hospital. For example, NPs can’t prescribe controlled substances in Florida. In some states, a supervising physician needs to be on site when a PA treats you; in other states, it’s not necessary. Nationwide, an NP’s or PA’s authority to admit you to a hospital is up to the hospital.

Training differs, too. Doctors and PAs train under the so-called medical model (though primary care doctors have about 23,000 hours of education and training, PAs have around 3,000). That teaches physicians to “work through a diagnostic process that directs the questions you ask, the physical you perform, the diagnostic studies and treatments,” says Reid Blackwelder, M.D., chair of the American Academy of Family Physicians’ board of directors. Nurse practitioners are educated under the nursing model, which stresses health promotion and education.

Ultimately, what an NP or PA does in your doctor’s office will depend on his or her experience, the setting, and the speciality, notes Marc J. Moote, PA-C, chief physician assistant at the University of Michigan Health System in Ann Arbor. “Often, each physician/PA/NP team will decide the best use of everyone’s skills on the health care team, and this can vary from practice to practice,” he adds.

6 big benefits
NPs and PAs are indispensable in handling everyday problems such as sore throats or urinary tract infections, freeing primary care doctors to handle more complex conditions, says John Santa, M.D., medical adviser to Consumer Reports. They can also prescreen patients, make hospital rounds, do follow-up care, monitor treatment, manage chronic conditions, and have a place in specialty care as well. “They can be very good at the history taking, reviewing a patient’s records, and coordinating everything the specialist needs,” Santa adds. What’s more, many PAs work as surgical assistants. Though seeing an advanced practice practitioner is unlikely to lower your co-pay, it can help reduce overall health costs. Other benefits may include:

Shorter waits for appointments. Merritt Hawkins, a health care search and consulting firm, found that in 15 metropolitan areas, new patients wait, on average, 18.5 days to see a cardiologist, dermatologist, family physician, obstetrician/gynecologist, or orthopedic surgeon. But with more providers in the office, the PA or NP can see a patient if the doctor can’t.

A team approach. Having an NP or PA on staff makes some aspects of team-based health care more feasible. He or she can check a cough, cut, or sprain, and ensure vaccinations and blood pressure and cholesterol checks are done. A 2013 review in the Journal for Nurse Practitioners reported comparable blood glucose and blood pressure levels in people cared for by NPs as in people seen by doctors.

Convenient care. NPs and PAs staff some walk-in clinics at drugstores. So if you develop a urinary tract infection, for example, you can get the care you need ASAP.

Faster emergency-room treatment. Canadian researchers have found that in ERs with NPs and PAs on duty, people without life-threatening symptoms were twice as likely to be treated within 15 to 60 minutes.

Help with chronic conditions. Once you and your physician decide on a treatment, a PA or NP can make sure it’s going smoothly, for example, that your blood glucose levels are well-controlled.

APPs are especially helpful for seniors with chronic illnesses. A study in the Journal of the American Geriatrics Society noted that older patients managed by both an NP and a physician had higher quality care for dementia, falls, and urinary incontinence than those treated only by a physician. Co-management “is most appropriate for conditions that require a lot of close monitoring, patient engagement, and education,” says study co-author David B. Reuben, M.D., chief of the division of geriatrics at the David Geffen School of Medicine at UCLA.

Lower risk of hospital readmission. Leukemia patients in the hospital for chemotherapy cut their stays by about 6 days and were less likely to be readmitted within 14 days when cared for by PAs instead of doctors in training, according to a small study in the Journal of Oncology Practice. A 2013 study in the Journal of Thoracic and Cardiovascular Surgery found that when PAs make home visits to heart surgery patients as part of a PA home care program, it lowered 30-day readmissions by 25 percent.

See our Guide to Doctor Ratings and get advice on how to choose a doctor.

When to stick with a doctor
More research is needed to definitively assess when seeing a doctor might be preferable to seeing an NP or PA. Advanced practice practitioners have the know-how to play a primary role in diagnosing and treating common ills and an auxiliary role managing complex ailments, says Marvin M. Lipman, M.D., chief medical adviser to Consumer Reports. “Doctors are good for those 5 to 10 percent of patients whose symptoms don’t add up and need more detailed investigation,” he notes.

NPs and PAs say they can handle more than routine tasks. “It’s a misconception to assume they can’t diagnose or manage complex care,” Moote says.

That said, some research suggests physicians may be more skilled in some areas. For example, one 2013 study found that family physicians who referred patients to a medical center better understood what the symptoms might suggest and were more likely to order the right tests than NPs and PAs. The doctors’ referrals showed “a much more logical approach,” says William Mundell, M.D., assistant professor of medicine at the Mayo Clinic in Rochester, Minn. “They were getting closer to the diagnosis.”

Another key question: How many tests are different types of providers ordering? Recent research in JAMA Internal Medicine found that NPs and PAs tend to order slightly (less than 1 percent) more imaging tests than primary care physicians for similar Medicare patients.

The takeaway: All of those providers have an important place in health care. Make sure that you see the right one for you at the right time.

Editor’s Note:
This article also appeared in the August 2015 issue of Consumer Reports on Health.

NOT SURPRISING NURSES ARE THE MOST TRUSTED PROFESSIONALS

NURSES ARE THE MOST TRUSTED PROFESSIONALS

This is from the Medscape Medical News

Nurses Remain Nation’s Most Trusted Professionals

Jenni Laidman  Dec 06, 2012 Authors & Disclosures

Medical professionals are among the most trusted people in the United States, a new Gallup survey shows, with 85% of survey respondents ranking nurses highest for honesty and ethics, followed by pharmacists (75%) and physicians (70%).

The 2012 sampling was conducted via telephone November 26 through 29 among 1015 people aged 18 years and older in all 50 states and the District of Columbia. The survey results, published December 4, have a margin of error of ±4 percentage points and a confidence interval of 95%.

The poll asked respondents, “Please tell me how you would rate the honesty and ethical standards of people in these different fields — very high, high, average, low, or very low?” A list of 22 professions was then provided in random order to each person contacted. Spanish-speaking respondents were interviewed in Spanish.

Nurses, who have led the rankings for 11 consecutive years, were ranked “high” or “very high” for honesty and ethics among 85% of respondents. The survey has been conducted annually since 1976, and nurses were first included in 1999.male and female nurse

“This poll consistently shows that people connect with nurses and trust them to do the right thing,” said American Nurses Association President Karen A. Daley, PhD, MPH, RN, in an association news release. The only time nurses were not first on the list was 2001, after the terrorist attack of September 11, when firefighters ranked first. Firefighters have not been included in polling in any other years.

Engineers tied with physicians for third place, ranking 70%, followed by dentists at 62%, police officers at 58%, college teachers at 53%, and clergy at 52%. Psychiatrists ranked eighth, at 41%, and chiropractors ninth, at 38%, followed by bankers (28%) and journalists (24%).

At the very bottom were car salespeople, with 8% ranked high or very high, and members of Congress, at 10%.

Medscape Medical News © 2012  WebMD, LLC

Send comments and news tips to news@medscape.net.

Cite this article: Nurses Remain Nation’s Most Trusted Professionals.  Medscape. Dec 06, 2012.

DEMISE OF THE PHYSICAL

Back in the early ‘80s when I ran a not-for-profit clinic on the west side of Chicago for older people before annual physicals were considered “nonspecific” or “inefficient” or “potentially harmful” [“Let’s (Not) Get Physicals” (Elisabeth Rosenthal, The New York Times, June 3, 2012)] I did a complete head to toe exam on each patient who registered, including vaginal exams on the women and rectal exams on the men.

I enjoyed the mechanization of the whole process. Take out your reflex hammer. Tap elbows, wrists, knees, and heels. Put it away. Take out your stethoscope. Listen to lungs, heart and bowel sounds. Put it away. Methodical and expedient. A whole hour was allotted to this first visit. Hard to believe in light of today’s harried health care system.

I remember telling myself to keep my facial expression bland. The slightest furrow on my brow shot a message to my patient—she found cancer or something equally horrible. As if the physical exam was an accurate barometer of health and well-being. As if I, the nurse practitioner, a.k.a health professional or primary care provider, had some secret connection to the Almighty and not only could find abnormalities but could predict life expectancy.

The physical seemed like a test or maybe a comparison of one older person to his/her peers. I can see Mr. Brown sitting at the edge of the exam table as I auscultated and percussed and said such things as “great lungs sounds” or “your heart beat is strong.” And after the exam I pronounced “you’re in great shape.” His smile radiating as he stepped down from the exam table probably thinking of himself in better shape than others his age. Then the common compliment: “That was the best exam I ever did get!”

Although I no longer practice as a nurse practitioner, I mourn the demise of the complete physical. Back thirty years ago when nurse practitioners were attempting to secure our identity as primary health care providers, the physical exam was a powerful tool signifying we could do what doctors did. And Medicare reimbursed this service. It was a vehicle to get us where we wanted to go—to become legitimate in the eyes of our clients and employers.

The physical, like my first car the gold Studebaker convertible my dad bought me that already was 12 years old, was serviceable but became too expensive and unreliable to keep forever.

But what a great ride.

My car was gold and in better shape.