Think twice before throwing doctors to the wind

Original Reporting | By David Noriega |

Difficult to measure

Golden and other nurse practitioners say that physicians’ claims about their diagnostic abilities are not backed up by any evidence pointing to higher rates of misdiagnosis by nurse practitioners. “If we could not recognize [such cases], you would see a lot more lawsuits against nurse practitioners for not recognizing them, but those lawsuits aren’t there,” Golden said.

In places where nurse practitioners have independent practice, people aren’t dropping dead in the street because they’ve seen nurse practitioners. — Polly Bednash

This argument is consistent with one made frequently by nursing groups that advocate expanding their scope of practice. There are 16 states (plus Washington, D.C.) that allow nurse practitioners to provide primary care with full independence — that is, without a mandated supervisory relationship with a doctor. These states, they say, are not racked by problems caused by independently practicing nurses.

“Any clinician can miss things and make a misdiagnosis,” said Bednash, of the AACN. “But there shouldn’t be the assumption that because an individual is a nurse practitioner, that’s more likely to happen. That’s an inaccurate assumption. In places where nurse practitioners have independent practice, people aren’t dropping dead in the street because they’ve seen nurse practitioners. There is no evidence out there that in those states we see a much higher incidence of malpractice occurring, and that patients are being harmed.”

But physicians say that death and malpractice rates are not proper metrics by which to measure the differences involved. Rimsza, for example, chairs the child fatality review program in Arizona, a state that allows independent practice by nurse practitioners. But, Rimsza said, there are so few nurses practicing pediatric primary care independently throughout the state (most of them work in team-based clinics) that it is practically impossible to assess whether any of the small number of preventable deaths every year can be directly ascribed to nurse practitioners. “You can’t expect to come up with those statistics,” Rimsza said.

Moreover, cases of preventable death do not capture instances of delayed diagnosis. “Although there might be delays in diagnosis,” said Rimsza, “fortunately most kids can survive.” In other words, the differences, while difficult to measure, are far from trivial in their potential consequences for patients: a delay in diagnosis means more suffering for the patient before the condition is mended, or, at the very least, more inconvenience in navigating the health care system with the burden of an ambiguously diagnosed condition.

Similar cautions exist when using malpractice lawsuits as a rubric for comparing treatment, said Perry A. Pugno, vice president for education of the American Academy of Family Physicians. “In those states where independent practice is permitted, the number of [nurse practitioners] actually doing independent practice is very small — vanishingly small,” Pugno said. “When people are cared for by nurse practitioners, they tend to be people who aren’t real sick, who don’t have complex, significant illnesses. And when the patient isn’t getting better, or things don’t seem to be going right, the patient will leave that [nurse practitioner] and go see a physician, but they won’t turn around and sue the nurse practitioner for not having figured out what’s wrong. So malpractice is a very poor, very blunt instrument for doing those kinds of comparisons.”


Why not ask, “What’s best?”

Furthermore, such metrics approach the question from an angle that some physicians consider to be problematic in the first place. “I think the argument should be more, ‘What’s the best care for kids, and how can we provide it to them?’” said Rimsza. “Not, ‘Let’s look at how many people die if you let someone do x, y, or z on their own.’”

“I think the argument should be more, ‘What’s the best care for kids, and how can we provide it to them?’” said Mary Ellen Rimsza of the American Academy of Pediatrics. “Not, ‘Let’s look at how many people die if you let someone do x, y, or z on their own.’” 

More energy, Rimsza said, should be devoted to thinking about how these two professions can be best coordinated to provide the highest-quality primary care possible for patients of any age. Otherwise, we miss out on a discussion about what kind of care is best and settle for one about what kind of care is adequate or acceptable.

“I think that the scope-of-practice issue tends to be more a discussion about what people should be allowed to do, more than what is the best way to manage care,” Rimsza said. “What the team should be, how they should be working together, and what resources should be available for each team to be successful.”

Within these teams, both nurse practitioners and doctors have different and important roles to play. “I should say that I work with nurse practitioners every day,” said Rimsza. “They’re an important part of the health care team. I have no problems with having nurse practitioners take a lot of responsibility, and I trust them with what they do. The problem is the blanket comment that they’re interchangeable professions. They really aren’t interchangeable. They all have their role.”


How the machine works

In addition to the benefits that physicians say accrue from many hours of practice, several medical educators pointed to differences in the pedagogical approach to teaching medicine and nursing. Pugno, who has mostly worked in medical education but also co-directed the nurse practitioner program at Loma Linda University in California, said the different educational methods lead to substantially different approaches to care.

“Nurse practitioner training tends to be more pattern-recognition–focused,” Pugno said. “When a nurse practitioner is presented with a patient scenario, their training level allows them to consider the top two or three likely diagnoses that that constellation of symptoms would represent. And their training is also based around a relatively protocol-based response to that diagnosis — if you have Diagnosis A, it’s Therapy B.”

By contrast, doctors are prepared to consider a much broader and deeper range of possibilities with any given patient. “You understand how the machine works,” Pugno said. “Kind of like a mechanic learning how to totally disassemble an engine and put it back together — you need to understand how every part works, so that you can figure out when something goes wrong.”

Pugno ascribes much of this difference to the length and intensity of coursework. This disparity is often evident in side-by-side comparisons of medical and nursing school curricula. For instance, the curriculum for the University of Iowa’s Master of Nursing Practice program includes several courses in advanced medical topics, but these topics are relatively broad: applied epidemiology, for instance, or physiology and pathophysiology for advanced clinical practice.

A typical medical school curriculum reflects more focused, intensive coursework. Take, for instance, the University of Oklahoma (ranked 71st by U.S. News & World Report), with course modules dedicated to specific biological systems: one such module covers cardiovascular, respiratory, and renal systems; another covers gastrointestinal and hepatobiliary (bile-producing) systems.

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