Nurse Practitioner vs Doctor?

My experience wasn't especially unfortunate, as I did end up getting appropriate treatment. What was alarming to me was the statements made by the nurses that revealed a degree of outright medical ignorance that speaks to the inadequacy of their training. It's just way less rigorous than medical training, especially when the NP is not working in a limited specialty.

The next day, I did see a note on the door of the Urgent Care clinic that said that patients complaining of abdominal pain should bypass U.C. and go directly to the ER.

What I said about D.O.s is that they come out of programs whose admission standards are generally less selective than those of medical schools that train MDs. Make of that what you will. (I'll cite a reference when I'm not on a mobile device.)

I actually did go to a DO once, who told me that my neck pain was a myofascial problem and totally reversible. An MD told me it was degenerative disk disease, and that is not reversible. The radiologist's report on my xray and MRI supported the opinion of the MD. I would not have a DO as my primary provider, but that's just me.

Here is some source links to substantiate my assertions above:

"Osteopathic physicians are licensed to practice in all states. The admission standards and educational quality are a bit lower at osteopathic schools than they are at medical schools. I say this because the required and average grade-point averages (GPAs) and the Medical College Admission Test (MCAT) scores of students entering osteopathic schools are lower than those of entering medical students [4,5]—and the average number of full-time faculty members is nearly ten times as high at medical schools (714 vs. 73 in 1994) [5]. In addition, osteopathic schools generate relatively little research, and some have difficulty in attracting enough patients to provide the depth of experience available at medical schools [6]. However, as with medical graduates, the quality of individual graduates depends on how bright they are, how hard they work, and what training they get after graduation. Those who diligently apply themselves can emerge as competent." Dubious Aspects of Osteopathy

"Finally, there is data that shows that students enrolling at colleges of osteopathy have lower grades than students entering medical schools, suggesting (though this is not proof, of course) that D.O. schools provide an alternative route to a medical degree for those who aren’t good enough to get into normal medical schools." Osteopaths Versus Doctors - Forbes

Thank you for the citations, Rose. Some of this information is quite old. You are correct in stating that GPA and MCAT scores are lower though. I did some research (current data) on this awhile back since we have an Osteopathic medical school about ten minutes from my house. I think, however, that entrance is only a part of the experience. You would probably gain more from the first couple years in either D.O. or an M.D. program than you did all of your years in undergrad. Also, you must factor in residency. I think by the time they come out both are going to be quite competent in their specialty.

Compared to M.D.s, D.O.s are philosophically more disposed to value and prescribe "alternative" type treatments. Here is a quote:

"The percentages of DOs involved in chelation therapy, clinical ecology, orthomolecular therapy, homeopathy, ayurvedic medicine, and several other dubious practices appear to be higher among osteopaths than among medical doctors. I have concluded this by inspecting the membership directories of groups that promote these practices and/or by comparing the relative percentages of MDs and DOs. listed in the Alternative Medicine Yellow Pages [4] and HealthWorld Online's Professional Referral Network. The most widespread dubious treatment among DOs appears to be cranial therapy, an osteopathic offshoot described below."

Dubious Aspects of Osteopathy

I, personally, have an aversion towards "alternative" type medicine. Someone else might think that they want a doctor who will offer them the broadest range of therapies, including "alternative" type remedies. So, I guess, it gets to be a matter of taste and philosophy and "bent" of mind.

I think of traditional, orthodox medicine (as opposed to alternative medicine) as being more scientific. At the same time, I recognize that, at times, mainstream medicine has promoted treatments that were worthless and even harmful. Remember, "blood letting," a technique that came from mainstream practitioners. Also, mainstream practitioners have a history of being slow to give new, worthwhile modalities a chance. I'm thinking of the treatment of polio advocated by Elizabeth Kenny that was resisted by mainstream physicians whose thinking has turned out to be wrong on that.

So I will not say that one system of medical thinking is always superior to the other. I also know that, in order to get a license to practice medicine, D.O.s must satisfy a quite rigorous set of requirements. I do trust that they are basically competent.

I understand your aversion to "alternative" medicines because some are definitely quackery! However, some alternative medicines such as honey or maggots work quite well. In my opinion, we should put more research into non-pharmacological treatments for disease. Otherwise, we are going to have a major pandemic from the overuse of antibiotics. This is where “orthodox” medicine and our society as a whole fails miserably. We should never put all of our eggs in one basket, or close our eyes to possibilities.

You make a very good point, tradika . . . a couple of good points, actually.

An awful lot of what goes on in mainstream, or allopathic, medicine is driven by profit. No one can take out a patent on maggots, so not a lot of money can be made using them as a modality of treatment. Big pharma heavily pushes the treatments that it can make a profit off of because it holds patents on those products. They are not always superior, or even as good, as simple things that are not patented. Allopathic (traditional mainstream majority) doctors tend to be very susceptible to Big Pharma propoganda. So I agree that it is very healthy that they get competition from the non-mainstream, or alternative, wing of medicine.

Why don't we in the U.S. hear more about the use of fecal transplants to treat loss of normal intestinal flora, when the Australians have been getting good results with this for a long time? Could it be just because no drug company can patent human excrement?

I fully agree that we benefit from there being different traditions of practice open to different modalities of treatment. This leaves the door open to charlatans, but I do like there being a market place of ideas that fosters diverse approaches. I've chosen the one that is going to be my mainstay, but I will never assume that that approach knows all there is to know.

Mainly, people should read about the differences among various types of practitioners and make an informed choice. Also, there is no credential that guarantees the character of a practitioner . . . level of conscientiousness, willingness to listen, accountability for outcomes, etc.

Whatever I may think of non-MDs as PCPs, the fact of life is that there will be more and more of them delivering a greater and greater percentage of primary care in this country. The day may even come when you can't see an MD, unless a PA or NP refers you to one (unless you pay extra for the privilege.) Somehow or another, the cost of healthcare in America has to be brought down. Using less expensive providers to do what they can, indeed, do competently is part of what will make that happen. But that means that practitioners must restrict themselves to their scope of expertise and know when they are getting in over their heads. Right now, I see NPs having a tendency to think they know more than they do. We are in a period of transition, and all the kinks have yet to be worked out, in respect to how decision making responsibility is allocated amongst various levels of clinicians.

In 1982, I experienced severe anxiety at work and was sent to the Nurse Practitioner in Employee Health. She suggested to me that I might be "allergic" to fluorescent light. This is the kind of inane crap that I have no patience with. Even if there were credible new theories about how fluorescent light might have a deleterious impact on some people, her remark showed a basic illiteracy on the subject of allergy. NPs are tending to incorporate into their thinking anything and everything that they read that excites their imaginations. Their intellectual training isn't rigorous enough to equip them with sufficient filters to all the "stuff" that is out there. IMHO, they are too soon allowed to fly by the seat of their pants.

The reason that mainstream medical schools recruit students whose undergraduate work is superior and who score highly on aptitude and achievement tests is that they are looking for candidates who already have demonstrated very high capacity for critical thinking. It's a skill that you don't want to have to try to teach a person who is beyond the age of 21 years. By then, either one has it, or one doesn't. Those who do tend to be attracted to the more demanding academic arenas.

As someone who attended nursing school, I can report that having a penchant for critical thinking is not the best way to endear oneself to one's clinical instructors. A lot of those instructors, themselves, are not there because they had any particular talent in that regard. Traditionally, nurses's training has been characterized by a "boot camp" mentality: "Show us that you can do what you're told to do, quickly and efficiently." It's more like the training of a front-line soldier. On the other hand, physicians are expected to be autonomous and that is part of the tradition of how they have always been trained. "Show us that you have good reasons for what you decide to do, even though your decisions sometimes will be wrong."

Nurse Practitioners don't go through a period of "residency" that is part of doctors' training. This is really scary. Residency allows new MDs, and DOs, to function independently, but have their work constantly under review by teaching staff. They spend a few years working under this kind of supervision. NPs basically go from school to treating patients. Yes, they get some supervised clinical experience, while in school. It's not enough, IMHO.

It’s unfortunate that psych-central won’t put an article up about when it’s time to find a new PCP. I am voting for allergies to fluorescent lighting to be in the top ten! As horrible is that is, I had to laugh a little bit that someone would actually say that.

I am currently doing my pre-reqs for nursing. So, I’m sure I will see more of these fun things you are discussing in the future. I have already seen the inability to critically think in a lot of the nursing students. It scares me on some level, but hey, maybe it will be my downfall and their boon. If it does go well though I would like to go the psych-NP route.

I have an acquaintance who is a NP. She started out working at a family practice, but now works at an urgent care center. She much prefers the urgent care center, and explained to me why.

At the family practice:

1. She had to work under the supervision of a physician.
2. She had to spend "too much time" talking to the patients.
3. The patients' medical problems were "too complicated."
4. She had to follow up with patients after she treated them.

At the urgent care center:

1. She is in charge.
2. She barely talks to the patients.
3. She is only expected to treat the patients' immediate symptoms.
4. She refers them to their family doctor for follow-up and so never has to see them again.

Obviously, not all NPs feel this way, but I certainly worried after hearing her opinion that this could be the attitude/culture among many in her profession.

So I much prefer seeing doctors for physical/medical issues. Incidentally, my psych med prescriber is an NP and for the most part she is great. I have been less satisfied with her of late as I have been trying to wean off of some meds so I can get pregnant. She just does not have a lot of knowledge about this particular situation. However, I have no idea if that has anything to do with her being an NP and not an MD.

That pretty much squares with my take on NPs.

As far as getting off psych meds, I've found that pdocs appreciate the difficulties and advocate a slow taper down. They appreciate that much better than general practice MDs, so probably a lot better than NPs.

Most of my pdocs didn't taper anything. Even drugs that cause withdrawals. I had to learn to do it on my own. What I would say to krm is know your medicine well. Don't just blindly trust the providers judgment. Also, some things can be used during pregnancy. If you still have an issue with meds then make sure you up your therapy! No sense in having severe ppd go unmanaged.

That's a real bad approach to stopping psych meds. It would turn me off going to any doctor who put me through a needlessly miserable ordeal.

Wait, are you guys telling me that I'm *not* allergic to florescent light? I'm self diagnosed, but... guess I shouldn't go into medicine

It took me a while to get caught up on this thread. There's no telling whether we will have a bad experience with a doctor or an NP, but the chances are good that we will have a bad experience with the medical industry in the US one way or another. The reason I haven't gone to the doctor in so long, despite having insurance for most of that time, was because I had some really negative experiences.

I lucked into a doctor. I had lunch with a friend who was bragging about his physical results. It turns out his female doctor was looking for new patients! I have an appointment for next month.

ETA: I think what turns me off about the NPs here is that they seem to be what I'd call first tier support. You see the NP who decides whether or not your problem is serious enough to warrant seeing a doctor. That makes sense from an efficiency standpoint, but from a patient standpoint, there's no benefit to me in seeing an NP first. It just means that I have to make two appointments instead of one, that I have to wait 12 weeks to get my problem resolved rather than 6. I personally pay the same amount of money no matter who I see. The insurance company and medical practice seem to 'get' that there's no incentive, so they don't let you choose a doctor as a PCP.

Aside from my disastrous experience, I have a lot of health problems. At that clinic they never once referred me to a specialist!

A psychiatrist tapered me off of amitriptyline at the rate of dropping the dose by 5 mg per month. That took 9 months. (Even doing it that slow, I had GI upset half ways through.) Another psychiatrist told me to expect to need a year to get off of Restoril. But I did manage that in about 4 months.

These were both drugs that I had been on for years, prior to the taper. At the very least, you'ld expect a psychiatrist to be appreciative of the difficulty of getting off any psychoactive drug. I'ld have no faith in one who wasn't.

Unfortunately I have no access to good doctors in my area. Just NPs and a horrible pill mill pdoc.

This is what the real healthcare debate in America is going to be about.

Obamacare is not going to be repealed and Ted Cruz knows that better than I do. The real debate is not whether or not we are going to have government financing of healthcare. That's now an accomplished fact. The real debate is going to be about how much should we spend on healthcare for the masses.

America is nowhere close to becoming like some Socialist nations that insist that everyone have access to the same kind of care. I, for one, don't think we have to even go that far. The well off will always have a way of getting better care than the not so well off. The real argument in the USA is going to be over: how big should the difference be?

Designing a system where you can't even see a doctor, unless a nurse-gatekeeper allows you to get past her, is one way of differentiating what the masses will get from what the elite will get.

Healthcare organizations are replacing insurance companies. Since they can't charge that premiums that will support the system continuing as it is, they will have to cut costs. Taking away a lot of choice is exactly what they are doing - and have to do - because there is no incentive for individuals to not always go to the best, and most expensive, provider.

People think Obama lied when he said that everyone could keep their doctors. We are seeing the beginning of the reality of people not even having primary care doctors, never mind the doctor of choice. But that's the way things are going to go.

It makes it all the more important for people to get regular checkups. Having the NP as primary provider will work better when the NP knows what is "normal" for a given patient. So, if I find myself having a NP as my main provider, I am going to be in that office with as great a frequency as I can arrange. Follow-up visits will become more important, as NPs will need those to catch the greater number of mistakes they will make compared to PCP MDs.

Yes, this is it. The game has changed so much from the last time I used medical services. There are no more MDs with their own practice, just 'health care teams' working out of hospitals and clinics.

I actually think that is a move in the right direction. Doctors operating their offices as independent businesses is wasteful in my opinion. The Cleveland Clinic has been written of a good deal as being on the forefront of evolving the modern American healthcare infrastructure. Here's a bit from a publication they put out about their "model" of healthcare:

■ Tier 2: The next tier in our
system is comprised of our 16
suburban Family Health and
Surgery Centers, where we offer
primary care, family health, and
specialty services ranging from
cardiology to colorectal surgery to
plastic surgery. These are primary
access point for our main campus
services. Many of our main campus
physicians rotate in and out
of the Family Health and Surgery
Centers during the week

From: http://my.clevelandclinic.org/ccf/me...a-mar-2011.pdf

When they talk about physicians "rotating" in and out of these family health venues, I wonder if that implies that they may even be getting away from the concept of even having PCPs who are physicians. Maybe they're talking about specialty docs.

Much is going to evolve over the next few decades, and much will change away from what we are used to. A lot of that will be good, but we must be advocates for ourselves. Sometimes you have to push to see who you need to see.

We need to get healthcare disentangled from the profit motive, I think. What I like about Cleveland Clinic is that it is non-profit and excels. My understanding is that the doctors on the premises of Cleveland Clinic facilities are there as "employees," rather than as independent practitioners with "visiting privileges," as in the old traditional model of healthcare. Personally, I like that set up that CC operates.

It's interesting. I think the Cleveland Model looks good on paper, but I am skeptical of those types of set ups working out well in real life. I keep thinking of the way tech support works. You call up, talk to someone reading off a script who may or may not speak English. They make you do things you've already tried before escalating you to someone who can help.

If the Cleveland Clinic escalates patients on the same day, that is a step above what the for-profit clinic in my area with a very similar model. Here, you have to schedule another appointment. It may be an efficient system for the clinic, but it is terribly inefficient to have me take off from work multiple times when I know that my issues require the second tier straight out of the gate.

On the other hand, as someone who provides higher tier support, I want my calls screened I don't want to waste my time and get burnt out dealing with people who can't perform basic tasks. Hmm...

I still don't want to go through first tier support. I'm an educated consumer. If I only need to see a first tier person, I can figure that out myself. If I haven't been to a doctor in nearly 20 years, my single annual physical is not going to be with a first tier support provider. I get one shot at this before it comes out of my pocket.

It might be different here because we are so rural and our choices are so limited. Our hospitals are, for the most part, really bad. Almost all of the doctors in my area are now employees of the larger hospitals or smaller boutique clinics. Now instead of being able to see an independent consultant who has an incentive to treat you well, you see people who work in a hospital that is the only show in town. The employees are poorly treated and there aren't any other options. There's no incentive to treat the patients well aside from whatever sense of responsibility and compassion the individual employee has.

There are a lot of advantages to having doctors be employees rather than entrepreneurs, but subsuming them into dysfunctional organizations seems like a step backwards. The Cleveland Clinic looks interesting, but any system built to work with our broken insurance system seems doomed...

Like you, I would prefer to see a physician right away. Having to see a nurse does strike me as a waste of my time. (I'm a nurse myself.) But I recognize that costs have to be reduced. What I think would appeal to me would be a set up where there are always doctors on the premises to whom a NP can refer a patient for immediate attention, when the problem is appropriate for that referral.

The Urgent Care clinic that I recently went to did not have a physician on the premises, though there were plenty of docs just down the hall in the ER that is housed in the same building. These nurses did a poor job of evaluating me and sent me out misdiagnosed. I wanted to believe them because I didn't feel like sitting in the ER. That showed me the pitfall of having NPs screening acute situations with no direct access to physician back up.

Six years ago, I went to a different Urgent Care clinic that did have MDs on the premises. I went there with a similar complaint. At that place, I was triaged to be seen by a physician and got the appropriate eval and diagnosis.

I guess my main problem is that I can't see having NPs working without pretty close collaboration with MDs.

Serious problems usually require some sort of imaging to diagnose. In the old style independent doctors office, there often was not equipment available to do x-rays. So you'ld still have to make a trip somewhere else for the image, then return to the doc for a reading. Family Practice clinics IMO should be big enough, with multiple providers, to make it worth the cost of having imaging capabilities right there. That does seem to be the trend.

Rural areas do pose a whole other set of complications in setting up a network. Having competition does seem to push quality up, and you get that in an urban setting.

I agree, on site and available doctors would make that system work better. I have run into this problem a couple of times with my grandparents. It's such a hassle to take them to their appointments in the first place that when they are misdiagnosed or referred to a doctor, it's incredibly frustrating. I would think that the place would know by now that whenever they see my grandfather, they wind up having to send him to a doctor - just send him to a doctor in the first place!

I'm ok with seeing a PA or NP, provided they are working under close supervision of a doctor that I am also seeing frequently, and it's not about anything serious. Otherwise my experience with them has been bad. The reality is that they are not as well trained as doctors, and seeing one instead of a doctor is a reduction in care. I think it's inappropriate for them to be working independently. I find I don't get the care I need. I'm not a simple patient. Good MDs are hard enough to find.

If you need to see someone though, and can't see a doctor, it might be ok until you can get an appointment. It might also help you to get an appointment with a doctor more quickly.

Access to care is a big problem in my community. It is easier and faster for me to be seen at a world class hospital an hour from where I live, even though I can't drive.

I worked with A few Nurse Practitioners and they seem to have worked well in a clinic setting... dealing with coughs, flu, strep etc... and all other patients were referred to a doctor. Also, they're only allowed to prescribe a certain classification of meds. I'd go with a doctor that you can rely on for all situations. Good luck

I had an NP and i thought he was great at first but then his inexperience started to show and i got maltreated and got really frustrated and got put on meds that made me gain 115 lbs in 2 years and he wouldnt do a thing about it. He just kept piling on the meds. Im still trying to go off of some of them. At one point i think i was taking 12 meds.

Now i have a psychiatrist and an md and i am being treated much better. They communicate with one another and with my therapist and they take my concerns into regard (most of thr time).

You know, I had another thought about this. The facilities that force their patients to see NPs rather than doctors might not have the best hiring practices. Since cost control seems more important to them than properly treating patients, maybe they apply that same mindset to hiring - maybe they go with cheap, improperly trained NPs?