Before I begin this article, I want to throw in the caveat that I am sure that there are many skilled nurse practitioners working in the world today, in addition, my opinion, should in no way influence your decision as to who you see for your medical needs.

I do not have to tell any of you who have been the unfortunate victim (I use the word lightly, since I doctorconfusedknow that it carries a negative connotation) of fluoroquinolone (FQ) toxicity that we are complex patients.  As a matter of fact, I would have to say that we are one of the most complex subset of patients that can be seen by a physician.  More often than not, we often leave the average physician scratching his head as to how to diagnose or treat our condition.  Keeping that context in mind, I have determined that I will never see another nurse practitioner again.

The impetus for this article came about when another floxed person asked me the other day if I would see a nurse practitioner for my health care.  My answer was, “been there, done that, and I will never make that mistake again, never!”  I have had several, unpleasant experiences with nurse practitioners.  Heck, I have several unpleasant experiences with physicians, so it would not be out of the norm for me to have had some with nurse practitioners.  Also, I want to emphasize that I am not talking about your normal hard-working nurse, who slaves away each day doing thankless jobs for many physicians throughout the world.  On the contrary, I find most nurses pleasant, understanding, and usually agreeable to get along with.

When reading the above some might assume that I am a difficult patient like the classic Seinfeld episode where, Elaine Benes learns that she was once labeled a “difficult” patient because she wouldn’t cooperate with a nurse and change into a paper examination gown.  On the contrary, I am usually a very congenial patient, albeit one who is very educated in my own health conditions and wants to guide my own healthcare.  Is it abnormal that I carry my health records with me, including a copy of my genetics, when attending a medical appointment?   Evidently some practitioners see that as threatening.

Why won’t I see a nurse practitioner for my health care?  Well first it has to do with training. According to Reid Blackwelder M.D. president-elect of the American Academy of Family Physicians, nurse practitioners complete 5,350 hours of education and clinical training over five to seven years, which can vary from state to state, compared to primary care physicians who receive 21,700 hours of education and clinical training during 11 years, that is standardized and consistent regardless of state or school.  Now if I am too complex a patient for the average physician, I know I am going to be too complex for the average nurse practitioner.   But’s let continue on…

Dr. Blackwelder goes on to state that the additional training physicians receive brings extra breadth and depth to the diagnosis and treatment of all health problems, acute and chronic, as well as injuries, mental illness, health and prevention. A primary care physician is trained extensively to make the right diagnosis, even when symptoms are not clear. By contrast, nurse practitioner training focuses on ongoing treatment after diagnosis.

Here we get to the crux of the matter.  Dr. Blackwelder clearly elucidates the difference in the roles of the physician and the nurse practitioner; a physician’s primary focus is to make the correct diagnosis where a nurse practitioner’s focus is on treatment after a diagnosis has been made.

 Unfortunately this is not what is happening in many parts of the US.  Eighteen states in the U.S. have already passed laws allowing nurse practitioners to have independent medical practices in certain situations, and several more are considering it.   The reason for this has to do with problems in the healthcare industry and many insurance companies wanting to utilize less expensive options presented by the nurse practitioner.  However Dr. Blackwelder cautions that we need to think carefully about the implications of such changes for patients and the American health care system.  I agree wholeheartedly.

On a side note, I want to take a moment and address what I consider a fundamental psychological shift that has occurred in the patient-medical professional relationship in the world.  Although I see this trend lessening somewhat with the advent of readily accessible medical information, it is still a problem for some.  That trend is to see the physician as more than an equal.

Remember, as a patient you are paying for the services of the medical professional.  I have noticed many individuals who normally would be out spoken switch into a passive role while in the presence of a medical professional.  I feel that this trait is still left over from the ‘god-like’ persona that many people use to perceive of doctors and that was pronounce in our society for many decades if not longer.   Some doctors, and even nurse practitioners, still have this leader-subordinate role mindset.  If you encounter this mindset it may be wise to look for an alternative choice in practitioners.   If you need assistance in speaking with medical professionals you can read my article “No Hidden Agenda”.  But for now, I digress…

Whether you are for or against the Patient Protection and Affordable Care Act (PPACA), the truth is that many insurers will start directing more and more patients to less skilled practitioners to save money and to compensate for a shortage of physicians who either retire or drop out of the PPACA.  In addition it will also mean that many individuals with complex medical problems, like ourselves, will have negotiate  a more complex system or gauntlet of lower level practitioners until we can see a qualified physician.

I know that there are some reading this article that are saying to themselves, nurse practitioners are supposed to confer or refer to doctors in cases of complex diagnoses or diagnoses that are unknown.   Well, I agree that in integrated, coordinated, physician-led health care team this is supposed to happen.   But in my opinion, many times it does not.   I have heard too many stories from other floxed folks of unprofessional treatment at the hand of nurse practitioners who will not acquiesce and refer to a doctor but instead attempt to make diagnosis in areas of complexity well over their heads.

I, myself, have had several unpleasant interactions with nurse practitioners.  The unpleasant situations usually arise out of inordinate amount of time that is required to explain a medical condition to a nurse practitioner; A condition that most doctors find complex.  In my situation it got so bad that one nurse practitioner actually made a psychological diagnosis, well outside their pay grade, on my medical chart, that took me a lengthy amount of time and the threat of legal recourse to get removed.  Humorously not much unlike the Seinfeld episode with Elaine Benes, although in my situation I did not have the AMA calling me at home in the middle of the night.  However, overall, it was not a pretty situation and it was not my only one!

Dr. Blackwelder goes on to say that the answer cannot be to substitute care. He says that the model of patient-centered physician-led health care teams is the best. “This model has proven to increase the quality of care for patients and improve cost-effectiveness for the health care system. Independent practice of nurse practitioners has not solved the primary care access issues or improved health outcomes at lower costs in those states that now have it. It is not the solution.

Although I know that it is not always a panacea seeing a physician, for me, it is not worth my time, money, and even risking the chance of an improper diagnosis to see a nurse practitioner.  I will refuse every time, unless my doctor, who I trust, directs me to see one and the parameters of the visit are already known. However, cold-calling upon a nurse practitioner, where my condition is not known to them or they are not known to me, is never an option.

To close this article I will refer back to Dr. Blackwelder, “We value nurse practitioners. Family physicians work with nurse practitioners across the country. They are critical players on the health care team — but they are not physicians. A physician-led patient-centered medical home ensures we have the health care professionals we need and that every patient gets the right care from the right medical professional at the right time.

What is your opinion?

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