Follow up to “Families sound alarm on medical transparency after deaths of their children | NewsNation Now’

Alexander D. Lake, DO
Chair, Florida Medical Association Resident and Fellow Governing Council
Chair, Physicians for Patient Protection Resident and Student Committee

A recent WGN News Nation Now report from investigative journalist Rich McHugh highlights the needless deaths of Betty Wattenbarger and Alexis Ochoa-Dockins.  The report, tragically, comes as no surprise to physicians. These two angels left the world far too early with so much life to live, and there will be others, until those in authority identify and understand the underlying problem. In fact, in a prior blog post, I predicted these needless deaths based on identification of the core underlying problem.

There is no magic wand or unique pill to save a patient’s life. Becoming a physician must be one of the most competitive, demanding, and challenging professional pathways of all. Once you choose to become a physician, your life forever changes. Every day for the rest of your adult working life, you will be managing the care of someone who believes in you, trusts in your decisions, and puts faith in your advice. As a physician, you are promising to uphold an oath, a firm standard:

Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and my art; but if I break it and forswear myself, may the opposite befall me. -Hippocratic oath, 1923 Loeb edition translated to English

This leads to the core problem, a fundamental issue that will continue to negatively impact patients in the future unless we make adjustments now:

Nurse Practitioners (NPs) are not held to the same educational standards as physicians, and they are not held to the same patient treatment standards as physicians. Yet NPs seek to treat patients without any physician involvement.

Nurse Practitioner education lacks uniform standards, content, and rigor

Medical education for physicians is standardized and rigorous.  Medical students at every school complete the same coursework and the same core clinical rotations.

Nurse Practitioner education, by stark contrast, is not at all standardized.  Some schools require as little as 500 clinical hours of experience, while others require more (up to about 1600 hours).  Some NP schools are brick-and-mortar, while hundreds of NP schools are 100% online.  There are no accredited online medical schools.

Medical school examinations are standardized nationally at all levels and are comprised of questions that challenge second-order thinking.

Nurse Practitioner exams are comprised of first-order thought questions.  For example, “a patient has X problem. You can treat X with what medicine?”  Rote memorization can allow someone to pass an NP exam, since the NP just has to know that Y drug treats X problem.

By contrast, memorization will not get a medical student a passing score on her exams with second-order thought processes required.  Those questions are more like this: “A patient has X problem and is being treated with Y drug.  What lab abnormality can be anticipated by this combination?”  The test-taker has to understand the patient’s pathology, the pharmacology of the medication, and understand chemistry, physiology, and lab interpretation to arrive at the correct answer.

First-order training of Nurse Practitioners, memorizing key terms or facts,
does not adequately prepare an NP to evaluate and treat patients independently.

Patients don’t present as simple multiple choice problems.

Quality over quantity is critical in healthcare.

Physician Shortages and Rural Health Access: the Myth of the Nurse Practitioner “Solution”

Nurse practitioners propose that legislators solve the problems of a physician shortage and lack of rural healthcare access by allowing NPs to practice independently of physicians. The AANP, the largest NP advocacy group, highlights both real problems, but they are proposing the wrong solution.

The physician shortage can only be solved by more physicians.  Access to care in rural America can best be solved by getting physicians to serve in those areas. 

The physician shortage and lack of care in underserved areas are valid concerns, but the current approach of policymakers to use NPs to fill the void overlooks the fundamental concept of education. Replacing physicians with lesser-trained practitioners is problematic, as it can lead to dire outcomes for our patients.

Educational standards are far more critical than fulfilling a quota. As the late Steve Jobs said,

Quality is more important than quantity. One home run is much better than two doubles.

Advocates for nonphysician practitioners (Nurse Practitioners and Physician Assistants) often respond that, “There is research on this; there is data:  NPs lower healthcare costs, thrive in primary care and rural settings; it is working!”

While I was initially optimistic when I heard these arguments, I have learned that they are rather exaggerated. After all, if everything was as the NP lobby claims, why would a Google Scholar search for “Nurse Practitioner Rural Health” include a report stating that nurse practitioners lack the appropriate infrastructure to provide high-quality medical care in rural areas?

If rural care is to be one of the main arguments for NP independence, rural training should, at the very least, be taught in NP school. Rural areas tend to have more unsatisfactory socioeconomic conditions, higher alcohol/tobacco use rates, less education, and higher poverty rates. The underlying issue is not just a lack of infrastructure. How can we expect high-quality medical care from those without high-quality medical education?

In reality, this rural health selling point for independence is likely to become trifling. Is there a shortage of rural healthcare? Absolutely. However, as the COVID19 virus has made evident, telemedicine visits are quite useful. Telemedicine, consults with physicians, can be used to aid the NP or RN providing direct care.  There is a strong argument to be made for directing financial resources towards high-speed broadband internet services, computers, and iPads in rural areas than sending more NPs to rural areas.

There are truly not a vast number of ‘structural’ components needed to save a patient’s life emergently, which include basic life support, knowledge fundamental to all healthcare professionals. The problem arises when the distress is being hidden by our bodies aggressively fighting to survive, especially in younger patients, and is not recognized by the independent practitioner swiftly.  Telemedicine could at least allow a physician’s eyes to see the patient and identify that distress.

There must be rigorous standards required to practice independently as a medical professional.

The education of independent medical practitioners is critical to their success and to patient safety. Physicians should not be bullied for stating this obvious fact.  ‘Years in nursing school’ cannot be compared to years of medical training, as doctors undergo a minimum of 11 years (4 years undergrad pre-med course, four years medical school, at least three years residency) compared to 5-6 years for NPs.

Furthermore, graduates of online Nurse Practitioner programs should not be allowed to perform autonomous practice. It is more convenient, sure, and must be remarkably difficult not to go down this route, especially when the selling point to bring students into the programs is based on length of training, like this one at Georgetown.

Students cannot gain the same education online as they do in a classroom.

Online programs often include open book tests, online exercises with quick access to Google, ‘Quizlet, course hero’ and other similar sites with old test answers. 

Only in-person programs should be deemed legitimate to fulfill the necessary licensing requirements to become a Nurse Practitioner.

Independent practitioners should complete, at minimum, the following three prerequisites:

  1. Thousands of clinical training hours. 
    1. Physicians: A humane training program with 48 work-weeks annually, including 40 hours/d for 5 days a week would have 1920 hours in a year.  In reality, medical students routinely complete over 2000 hours of direct patient education just during the 3rd year of medical school.  By the time a physician completes residency training, he has amassed over 17,000 clinical hours (specialists accrue as many as 20,000 or more).
    2. Nurse Practitioners: Programs typically require a minimum of 500 clinical hours for the entire program (not annually–for the entire program). Requirements may range from 540 to 825 hours, with a nationwide average requirement of 686 clinical hours.
  1. Board examinations with >2nd order questions to assess critical thinking and knowledge.
    1. Example that assesses critical thinking (Physician training):
      A patient  Crohn’s disease presents with macrocytic anemia, fatigue, glossitis.  What is the problem?  The student must identify that Crohn’s most commonly affects ileum, know that Vitamin B12 is absorbed in the ileum, then understand that this patient’s symptoms are likely related to B12 deficiency.
    2. Example that does not teach critical thinking (NP training):
      A patient has a hemoglobin of 10 (low), with an MCV of 104 (high).  This is called what?  (answer: macrocytic anemia)
  1. Residency training in ALL specialties to certify qualifications for autonomy

From the AANP website:

NP Specialty AreasNP Sub-specialty Areas
Acute careAllergy/Immunology
Adult HealthCardiovascular
Family HealthDermatology
Geronotology HealthEmergency
Neonatal HealthEndocrinology
Pediatric/Child HealthHematology and Oncology
Psychiatric/Mental HealthNeurology
Women’s HealthOrthopedics

If Nurse Practitioners can subspecialize, you might expect this specific subspecialty training to use physician training (residency, fellowship) as a model to ensure qualification? This is not the case, as evidenced by this example from MD Anderson Cancer Center’s “Oncology Nursing fellowship.”

“The Post Graduate Fellowship in Oncology Nursing is designed to provide advanced practice nurses an opportunity to experience a 12-month fellowship in oncology nursing at The University of Texas MD Anderson Cancer Center – recognized as one of the top cancer centers in the nation.”

In stark comparison, the physician fellowship in Hematology/Oncology is at least three years long. This is not meant to take any credit away from those in this program or other similar programs – but more to prove a point. How can we think a one-year fellowship in Oncology is sufficient to be an expert or even practice Oncology? I mean, could you honestly imagine sending your loved one in the darkest hours of their life fighting against cancer to someone you believe is a “doctor” that had one year in specialty training?

Perception is not reality.
Quantity is not better than Quality.
Nursing education does not include fundamental requirements that would allow an NP to work independently of physicians.

Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, President of the American Association of Nurse Practitioners (AANP) , says this: “Doctor is an academic degree. Doctor doesn’t mean physician. The physician world doesn’t own the term doctor.”

I agree that a Doctorate is an academic degree, and no, physicians do not solely own the title of “Doctor.” This is not an issue of semantics. We should not be looking at this from the perspective of healthcare professionals, but from through the eyes of our PATIENTS.  A person wearing a long white coat, a stethoscope, and a confident smile entering a room saying, “Hello, I am Dr. _,” undeniably instills hope, faith, and belief from our patients that we will help them feel better. I also have no doubt that the patient, hearing that introduction, fully believes he is seeing a Medical Doctor, a physician.

Sophia, I imagine you see how confusing this is from a patient viewpoint. Of course, we cannot forget that we are in this together to serve our patients to the best of our abilities. Why not advocate for nurse practitioner education to be in-person only, rigorous and similar to physician training? Perhaps discuss this with some of the more experienced, established nurse practitioners and ask them their thoughts. Many of them are outraged by graduates of online programs with minimal clinical hours fighting for independence.

If there is one thing we must do, it is to honor the tragic deaths of Betty and Alexis as a medical community:

May we as healthcare professionals have the courage to come forward not as persecutors of a profession, but as advocates of patient safety. Physicians, medical students, nurse practitioners, certified nursing assistants, licensed practical nurses, registered nurses, pharmacists, dieticians, physical therapists, occupational therapists, laboratory technicians, and all other members of the team acting as one. Our cooperation will ensure that we are giving our patients their best chance of survival.  The only way we can do this is together.