Pharmacists will be providing primary care. Maybe not you and certainly not me, but there are plenty out there who are well educated and up to the task. The powers at the bugaboo “The Affordable Care Act” are looking at you and nurses. It just makes good sense. Either you and Nurse Practitioners or millions get no primary care at all.
Not long ago, I attended a meeting on the future of primary care. Most of the physicians in the room knew one another, so the discussion, while serious, remained relaxed.
Toward the end of the hour, one of the physicians who had been mostly silent cleared his throat and raised his hand to speak. The other physicians smiled in acknowledgment as their colleague stood up.
“Nurse practitioners,” he said. “Maybe we need more nurse practitioners in primary care.”
Smiles faded, faces froze and the room fell silent. An outraged doctor, the color in his face rising, stood to bellow at his impertinent colleague. Others joined the fray and side arguments erupted in the back of the room. A couple of people raised their hands to try to bring the meeting back to order, but it was too late.
The physician had mentioned the unmentionable.
I remembered the discord and chaos of that meeting when I read a recent study in The New England Journal of Medicine of nurses’ and physicians’ opinions about primary care providers.
For several years now, health care experts have been issuing warnings about an impending severe shortfall of primary care physicians. Policy makers have suggested that nurse practitioners, nurses who have completed graduate-level studies and up to 700 additional hours of supervised clinical work, could fill the gap.
Already, many of these advanced-practice nurses work as their patients’ principal provider. They make diagnoses, prescribe medications and order and perform diagnostic tests. And since they are reimbursed less than physicians, policy makers are quick to point out, increasing the number of nurse practitioners could lower health care costs.
If only it were that easy.
Three years ago, a national panel of experts recommended that nurses be able to practice “to the full extent of their education and training,” leading medical teams and practices, admitting patients to hospitals and being paid at the same rate as physicians for the same work. But physician organizations opposed many of the specific suggestions, citing a lack of data or well-designed studies to support the recommendations.
In an effort to build consensus, the Robert Wood Johnson Foundation then invited a dozen leaders from national physician and nursing groups to discuss their differences. The hope was that face-to-face discussions would help physicians and nurses understand one another better and see beyond the highly charged and emotional rhetoric. The approach worked, at least initially; after three meetings, the group drafted a report filled with suggestions for reconciling many of the differences.
But an early confidential draft was leaked to the American Medical Association, a group that had not been invited to participate, and the A.M.A. immediately expressed its opposition to the report. Soon after, three of the participating medical organizations — the American Academy of Family Physicians, the American Osteopathic Association and the American Academy of Pediatrics — withdrew their support, and the effort to bring physicians and nurse practitioners together and complete the report collapsed.
Nonetheless, many health care experts remained confident, believing that the large professional organizations had grown out of touch with grass-roots-level health care providers. The guilds might oppose one another, but every day in medical practices, clinics and hospitals across the country, physicians and nurse practitioners were working side by side without bickering. Surely, the experts reasoned, providers who knew and liked one another would be receptive to trying new ways of working together.
Analyzing questionnaires completed by almost 1,000 physicians and nurse practitioners, researchers did find that almost all of the doctors and nurses believed that nurse practitioners should be able to practice to the full extent of their training and that their inclusion in primary care would improve the timeliness of and access to care.
But the agreement ended there. Nurse practitioners believed that they could lead primary care practices and admit patients to a hospital and that they deserved to earn the same amount as doctors for the same work. The physicians disagreed. Many of the doctors said that they provided higher-quality care than their nursing counterparts and that increasing the number of nurse practitioners in primary care would not necessarily improve safety, effectiveness, equity or quality.
A third of the doctors went so far as to state that nurse practitioners would have a detrimental effect on the safety and effectiveness of care.
“These are not just professional differences,” said Karen Donelan, the lead author of the study and a senior scientist at the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston. “This is an interplanetary gulf,” she said, echoing a point in an editorial that accompanied her study.
The findings bode poorly for future policy efforts, since physicians are unlikely to support efforts to increase the responsibilities and numbers of advanced-practice nurses in primary care. And most nurse practitioners are unlikely to support any proposals to expand their roles that do not include equal pay for equal work.
Peter I. Buerhaus, senior author of the study and a professor of nursing at Vanderbilt University Medical Center in Nashville, is chairman of a commission created almost three years ago under the Affordable Care Act to address health care work force issues. But his group has yet to convene because a divided Congress has not approved White House requests for funding.
“We’re running out of time on these issues,” Dr. Buerhaus said. “If the staffing differences remain unresolved, we are just going to cause harm to the public.”
Still, by providing a clearer picture of the extent of these professional differences, the study should help future efforts. “It’s too easy to say that everyone should just get along,” Dr. Donelan said. “These arguments touch on the whole nature of these professions, their core values and how they define themselves.”
“It’s like when family members are warring over a sick patient,” she added. “We need first to acknowledge the others’ position and the full extent of our differences before we can reach any kind of resolution.”
From a Comment Made by PharmacySlave2000.
I see the AMA fighting to the death to hold on to their place at the top of the food chain. They MAY agree to let NP’s or PA’s take the lead under their watch but there is no way they are going to let pharmacists have any piece of that pie.
Jay Pee’s take, PharmacySlave2000, It will not be up to THEM. The AMA got all the power with The Durham-Humphrey Amendment. The first job of the AMA is to protect turf. At every turn, the AMA said that pharmacists are not good enough. Pharmacist counseling was interference with the doctor-patient relationship. Then, in the 1970s, pharmacists were given ”Drug Product Selection” discretion. That was simply which brand to dispense. Achromycin V, Tetracyn, Sumycin or simply Tetracycline HCl. The AMA squealed, “You can’t give pharmacists discretion like that. Patients will be harmed. Yama, Yama, Yama.” At the same time, they are checking the winter rentals at their ski chalet at Squaw Valley. The third class of drugs. The “Behind the Counter Class” to be sold only with a pharmacist supervising. Believe it or not, the slow-moving machine of the APhA was all for this. William S. Apple (APhA President at this time-1970s) went full-frontal. He wrote numerous articles promoting the Third Class of Drugs. He made personal appearances from the seat of President of the APhA. Those of us pharmacists who watched and could see how our profession could benefit financially and professionally were salivating in the stands. William S. Apple was truly an American Pharmacy hero. He led the APhA in a manner that kept that huge professional organization focused on the way pharmacists practiced as well as how our profession could help patients. Monistat Vaginal Cream sold OTC is ridiculous. Aunt Sally’s diagnosis of a “Yeast Infection” could cause Niece Brenda to buy Monistat and happily believe she will be cured. The bacteria in that warm moist place proliferates. Next is PID and she will never be able to have children. William S. Apple was right on. It looked very good. My friends and I did buy the champagne and the big cigars. The AMA came in late, but they came in hard. ”This 3rd party class is practicing medicine without a license.” No assholes, it is practicing pharmacy WITH a license. What does the AMA have against us. You know and I know that modern pharmacists can easily be a primary care provider and a superior prescriber. We won’t do surgery. We don’t want to. That is your job, Buster. Patient care, that’s the nurse’s job. The real reason that the AMA is afraid of pharmacists is because we hold the keys to the kingdom. Modern medical care IS DRUGS. Can’t you get that? The AMA is desperate that CMS not recognize us as independent practitioners with discretion. They fought like hell to make pharmacists not eligible to be paid directly for services rendered. CVS fought like crazy. They even approached the BOP in Massachusetts and challenged pharmacists having their own NPI. The AMA fought against us being allowed to have NPIs. Let us go back 60 years to the days before Durham-Humphrey. This was the peak of the era of the DRUGGIST. I was a kid, working at Cook Drug on Main Street. I watched patient’s come in and present their problem. The Druggist got them a drug for it and they were usually thrilled. I have no idea what he gave (Actually, I do know one remedy) them. These people chose “Doc”, the Druggist. They knew that “Doc” could help them without needles and scalpels. The doctor usually hurt them and they often did not get better. An example from way back. And this shit happened near the first part of the 20th Century. An older farmer worked hard to get the harvest in. The physical result was serious pain. Back, muscular, hip. The nearest town was 50 miles away. There was a Drug Store, run and owned by the Druggist. The doctor was around the corner. He had been to the doctor many times, taken himself or a hand who had hurt themselves. They needed wounds cleaned and stitched, but just pain. He would always go to the Druggist. Why (remember.. way back)? Because the Druggist would give him a sickening-tasting elixir that contained cocaine. No more pain. No contest. ”Doc”, the Druggist was the main man in that town.
I do not know what the politics was like near the end of the 1940s. Coming up with Prescription-Only and OTC classes cleared the track for medical doctors to run the medical care train. Pharmacy was relegated to the back of the bus where just about our entire job was dispensing. Think about it.
Then, think about this. You haters of Barack Obama most likely do not have problems with The Affordable Care Act. Get on board with Obamacare. It can save pharmacy’s ass. The brains who are designing the new system have already acknowledge in the media that pharmacists (with Pharm D) and nurses (with advanced degrees) are well enough educated to provide primary care. It will happen for only one reason. You and nurses are cheaper than doctors. Basically, you guys, Obamacare has thrown the gauntlet at the AMA. ”Show us proof that we cannot trust pharmacists and nurses to see patients or fuck you.” It will be “Fuck You” to the AMA. Young doctors don’t give a shit. They are team conscious and they are happy to get relief. An orthopedist does not need an appointment slot taken up by a weekend tennis player with a hyper-extended knee. The pharmacist can do that. And..he can get paid directly for it.
This is going to happen wicked fast. Those of you who take the advice of The Goose will have a rewarding career. Those of you who just want to dispense…Well, what the hell… CVS is gonna need RPhs to keep the metrics green. You will be a robo-dispenser, some kind of fairy phantom pharmacist. A grossly over-educated Advanced Technician.
I keep on insulting you guys on this and you take it. What the fuck? Where is your pride? Tell me I am full of shit and give me evidence. Remember, when you go after me, you are going after Goose and my tribe.