Nurse Practitioner vs Doctor?

Now that we have pretty thoroughly discussed the training of Nurse Practitioners, I would like to reiterate that I, personally, would not care to have a NP as my primary care provider. Where I get my care, there is an MD who is my primary care provider. There are a few NPs in that same practice. If I call for an appointment with my MD and he is booked up for quite a while, I have the option of seeing a NP. There is usually an NP who is available right away. So I have taken that option when I wanted to get seen right away. I'm fine with that. I get seen quickly, but I know that I can always eventually see my MD, if I feel I want to. Right now I have an appointment to see an NP for a pap test. My MD simply doesn't do pap tests. He turns that job over to the NP who is advanced certified in women's health. I'm fine with that. Doing a PAP test is something that any bright person can be trained to do. It's a technical skill.

I don't mind NP's having technical responsibilities, like performing PAP tests. But I'm not having any diagnosis of mine made by an NP. I will always insist on an MD for that. I am a nurse, myself, and I see that NPs are often not in the same league as MDs in terms of education . . . and, quite frankly, in terms of I.Q. They are trained to follow decision trees . . . not so well trained to do independent, critical thinking.

Angelique67,
I'm so sorry to hear that happened to you! Benzodiazepines always require a slow taper. And one would have to be extraordinarily brave to write "drug-seeking behaviour" in a chart unless there was an overwhelming and compelling reason to do so.

I hope that you have found a competent healthcare provider who cares for you, provides appropriate medication, and who does not label you.

Thank you Roi5. Unfortunately since it happened ive been hiding in my apartment just sitting on my bed because anything else causes too much anxiety. I haven't been anywhere since I went back to the clinic for meds last July (other meds) and I might have to go this month and I'm praying I can get out of it. I feel like this is the last stop for me, like my life is truly over.

ETA: She wrote drug seeking because I asked to see different providers at the clinic hoping one would at least do a slow taper. An 8 week taper is not a slow taper.

Angelique67,

I know we're veering a bit off topic, but there are some patients who taper benzodiazepines over a 26-week schedule. It's true that it can be done at 25 percent reduction every two weeks, but it is equally legitimate to taper over a much longer period of time.

And the much bigger question: why taper at all? If you're struggling so much with anxiety, maybe tapering isn't such a good plan. But that's for you and your healthcare providers to discuss.

I think you should address the "drug-seeking behaviour" comment. I think it is reasonable for you to say, "I'd like to discuss the diagnosis in my chart." Have a discussion about it. Above all, ask if it was coded on your chart and therefore reported to your insurer. You also have the right to put an addendum in your chart, but I think it's best to aim for dialogue rather than be adversarial.

Again, best of luck. It sounds tremendously uncomfortable for many reasons.

roi

I would have no problem seeing an NP for something as simple as a physical. A physical exam isn't rocket science. If you need a more experienced eye after that, they can always refer you to their physician colleagues, and I am a physician.
I think a basic rule of thumb that a lot of people seem to either be maybe not aware of or not willing to do is; if you're unhappy with how someone is managing your care, regardless of who they are, see someone else. No one says you're beholden to one specific person. See another NP or PA or physician.
Do I disagree with the laws passing in several states that allow PAs and NPs to practice independently. Absolutely. I don't think there are any circumstances in which they shouldn't be under a physician's direct supervision. That being said, a first year med student could handle a general physical.

I recently went to urgent care and was seen by two nurse practitioners. Their conclusion was the one I wanted to believe, and so I happily left urgent care believing not much was wrong with me. A day later, I was in the emergency room at the hospital, where I got appropriately tested and diagnosed by a physician.

Those two NPs were young. They hadn't been grandfathered into their jobs, despite outdated credentials. They had to have had master's degrees. So they are representative of their trade. I now think even less of NPs than I did before.

The first one I saw said I couldn't be too sick, since I didn't have a fever. That was a red flag of stupidity right there. But, like I said - I wanted to believe I was basically fine. The second one showed me an xray of my abdomen and incorrectly identified the body parts. That was so unbelievably stupid, but I was so disbelieving that I, with my associate degree, could possibly read an xray better than a NP, that I figured I must be wrong. (Turned out I wasn't wrong.)

Folks, I will now, unequivocally, say that the training of a Master's level NP is very, very significantly inferior to that of a physician. This is true even beyond what I believed 3 days ago. I am absolutely astonished at the low level of education and critical thinking capacity shown by these two women. I shudder to think of the fate of others who depend on them and wouldn't see the red flags that I saw.

I now believe that nurse practitioners are are a monstrous hybrid of nurse and doctor. Doctors must constantly make guesses, knowing that they are merely guesses. Their training impresses upon them that reality and a sense of humility about it. Traditionally, nurses have been trained to deal with facts and leave the guessing to the doctors. NPs have usurped the doctor's privilege of making high-stake guesses, without having the intellectual equipment to hedge their bets. They are dangerous.

While I'm on my soap box, let me add another caveat. Some insurance plans are now trying to steer their subscribers toward Doctors of Osteopathy, as an alternative to Doctors of Medicine. Why do you suppose that would be? If you need more than one guess, you don't understand anything about insurance companies.

People tend to get paid commensurate with their talent and the resources invested in developing that talent. It costs less to go to a college of osteopathy than to a college of medicine, and you don't have to be as smart to get in. So do the math.

However, no rule of thumb is universally true. Paramedics spend less time in school than nurses and get paid less (at least, traditionally.) While in the ER, I got most of my care from a paramedic, who seemed superbly competent at what she was doing. In fact, I've gotten care from nurses in ERs who were notably less competent.

Rose,

I am sorry that you had such an unfortunate experience with NPs, but I think it's safe to say that it happens routinely with MDs as well. I'm sure a lot of us have been on the receiving end of a medical mess.

As far as the comments on DO vs MD. Why do you think that a DO is much less intelligent overall than someone who is doing MD? The last time I looked at the cost of DO school it still ruled out most of the population.

There is a reason they call it "practicing" medicine. Regardless of NP, DO or MD, they are human and science is every changing. The margin of human error is just as high regardless of education. Because they are constantly practicing. I would look more for things in these people than just credentials. I would look to see how thoroughly the individual is looking at my situation versus what the degree on their wall says. Being thorough saves lives, not credentials.

To the original poster: I have had more terrible doctors than I have NPs. In fact I saw a doctoral NP and she was terrible. But that was the only NP I've seen who was terrible. But I could list off all the doctors who misdiagnosed my kidney stones, strep throat, committed me for no reason, and the list goes on and on.

In the end, take a little time and look around for someone you TRUST, regardless of NP or MD. Someone you can tell everything so they can really give you a good diagnosis.

Seesaw

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.