Think twice before throwing doctors to the wind

Original Reporting | By David Noriega |

Other nurse practitioners fail to explain why doctors’ extra training does not translate to the ability to provide superior treatment. “How we’re getting trained, how that’s different from one another — I do not believe it changes what we bring to the patient in primary care,” said Angela Golden, a clinical nurse practitioner and educator, as well as co-president of the American Association of Nurse Practitioners (AANP). “Because our outcomes are the same…We’re both getting to the same endpoint.”

However, physicians’ groups counter this by pointing to what they say are limitations to most of the existing research. Much of it, for example, fails to distinguish clearly between care provided by nurses independently and that provided by nurses under some kind of collaborative relationship with a physician. Moreover, most case studies track patients for only a period of a few months, thus missing long-term complications. Others track populations with diagnoses that have already been established — usually common conditions like hypertension — and thus neglect to capture problems or complexities in the diagnostic process itself.

In other words, while doctors tend to agree that nurse practitioners are able providers of a broad range of primary care services, they say that most of them are limited to the treatment of common conditions. The research, they say, fails to capture distinctions in the quality and safety of care that become salient when rarer and more complex situations arise. The differences they claimed can best be summarized as follows: care from a doctor can be more effective in avoiding delays in accurate diagnosis; and physicians are better able to manage patients with multiple, complex conditions existing simultaneously, as well as to act as mediators between a patient and a range of specialists.


Practice makes better

Remapping Debate asked several representatives of physicians’ groups — most of them with experience as both medical clinicians and educators — to outline these differences, and to explain how they result from the extended training that comes with a medical education. Perhaps the most common response was that the combined time spent in clinical training, in both clerkships and residencies, gives physicians an amount of practice that translates into sophisticated care: the more patients you see, of different kinds and in different settings, the more aware you are of the kinds of patients that exist in the world, and the more comfortable you are with every new one you encounter.

More training makes doctors “different” primary care providers, not “superior” primary care providers. — Polly Bednash, American Association of Colleges of Nursing

Reid B. Blackwelder, the president of the American Academy of Family Physicians who is also a practicing family physician in Tennessee, said that, for example, residents are expected to have 1,650 patient encounters in outpatient settings (i.e., outside of hospitals). That number of encounters gives doctors-to-be a broad range of experience before they even start practicing independently.

Blackwelder and other doctors acknowledged that quantity and repetition do not necessarily translate to higher-quality care — but, they say, it substantially increases the likelihood that a physician will feel comfortable in any given situation. “A number doesn’t guarantee competency,” said Blackwelder. “Just because you’ve seen or done something x number of times doesn’t mean you’re really good at it…But the more hours you put into your craft, the more you bring to the table — the more likely you are to be a refined practitioner of that craft. And being refined and being competent — there’s at least some relationship between the two.”

Carol A. Aschenbrener, chief medical education officer for the Association of American Medical Colleges, said it’s not just the amount of practice involved in clinical training, but also the fact that that practice is graduated to expose the student to increasingly difficult tasks and to an ever-higher degree of decision-making and accountability. Because students spend a full five years in clinical training, this kind of progression can happen as deliberately and rigorously as it needs to.

In the first year of a clerkship, students begin making diagnoses under close supervision. “They have to present their findings and their differential diagnoses to both a resident physician and a faculty physician,” Aschenbrener said. “And they are asked questions, they are helped to see things they might not have noticed, they are helped to make connections, and so forth.”

“And as they get better and better at that, the faculty will see that they get more complex patients,” said Aschenbrener. “Then when they go onto residency training, they are doing more and more in terms of making decisions…[until] they can really have the responsibility of the physician.”


Practice makes safer

Under certain circumstances, doctors say, the amount of practice involved in a medical education becomes not just a matter of quality and sophistication but one of critical safety. Mary Ellen Rimsza, a practicing pediatrician, professor at the University of Arizona, and chair of the American Academy of Pediatrics’ workforce committee, said that pediatric primary care is rife with such circumstances.

“What we aim for in the education of physicians is a sufficiently deep conceptual understanding, not just of what’s known, but an understanding, or at least an appreciation, of what we don’t really know a lot about,” said Molly Cooke of the American Academy of Physicians. “That supports both routine expertise — ‘This looks like A and I’m going to treat it like A’ — but also the discrimination to say, ‘This doesn’t look enough like A to make me comfortable managing it as A.’”

The amount of hours spent in clinical training, Rimsza said, “is pretty important in pediatrics, where many of the life-threatening, serious diseases that we deal with can present as a common condition.” Rimsza used the example of an infant or child with a fever, which could signal either a common or easily treatable ailment (such as strep throat or an ear infection) or a life-threatening condition (like meningitis or sepsis). A pediatrician, Rimsza said, is particularly well equipped to tell the difference.

Nurse practitioners strongly take issue with the suggestion that they are more likely to misdiagnose patients. Golden, of the AANP, used the same example of a child with a fever, explaining that such a scenario is explicitly taught to nursing students.

“When I teach in the nurse practitioner program,” said Golden, “my students get a scenario of a three-year-old in the office with a temperature of 101 degrees. That’s it; that’s all the information they get. They have to come up with every possible diagnosis that could cause that fever.” Students are then given case studies, one of which “presents them with a physical exam that shows a very ill child. And their responsibility is to call an ambulance and get them to the hospital. We all know how to do that. We have been well trained to recognize ill children that should not be managed in the outpatient setting.”

Physicians, however, respond that the depth of knowledge that comes with practice and experience is more reliable than the knowledge that comes from simple instruction. “A lot of it has to do with the fact that you’ve seen lots and lots of children over time. You’ve had the experience of examining children, identifying subtleties in their behavior that might indicate a more serious illness versus a common one,” Rimsza said. “Since many of these diseases don’t occur very often, you have to have a lot of time in the clinical setting before you’ve seen very many of them. So if your clinical training is just for a few months in pediatric, the odds are you aren’t likely to see it.” In contrast, a pediatrician who has completed a full clerkship and residency will almost certainly have seen “thousands of children” with fevers and “certainly dozens of cases of meningitis.”

Thus, a pediatrician with this degree of experience is far more likely to notice subtle distinctions in a patient — such as variations in vital signals or details in the way an infant interacts with its surroundings — that suggest the possibility of something serious.

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