Dear Dr. Crankypants


I follow the Kevin MD blog because the blogs and guest blogs  present the human side of health care. Every so often the debate of the role of nurse practitioners comes up.  Mostly, these conversations are pleasant, but there is one physician that is so angry that nurse practitioners are allowed to practice at all. It may be that he has reasonable concerns, but the tone is so hateful and insulting.  His posts always boil down to the same points. Nurse practitioners are poorly trained and do not have the ability to diagnose anything because they lack the education that physicians receive in medical school. He says we order too many tests and consult too many specialists. The vitriol of his comments always takes me by surprise.

I really do try to understand his fears about us, but what I just can’t understand is the hatefulness of his tone. There is clearly so much emotion behind those comments. He talks a lot about how superior medical school is to nursing school.  It certainly is much longer and much more focused on the what I think of as the bits and pieces of people and not as much focused on the whole person. I don’t know for certain because I have never been to medical school.  In my mind, medical school is about microbiology, organic chemistry, pathophysiology and the other sciences.  I had those classes too, but I am certain not as advanced. I do think medical school is probably harder, and certainly longer. I am not sure it is the hard science classes that it make someone a better health care provider. He says we lack the ability to deal with complex situations. This is true sometimes. This is also true of physician primary care providers.

When I find myself in a situation in primary care that is very complex and sense that those thundering hooves belong to a zebra,  I am not prideful. I ask a physician if one is available. It is rare that they know the answer immediately. Mostly, when I say that I have a patient with these symptoms, and I thought it was this diagnosis and I tried a, b, c but they are not getting better- am I missing something? The answer I mostly get? Refer them to the specialist. So my physician colleagues in primary care don’t have all the answers either. I think experience with zebras makes the biggest difference.

He often says we are not smart enough to have been accepted into medical school. I am a couple standard deviations to the right on that damn bell curve. If I wanted to be a physician, I would be. I don’t want to be one. I don’t want to be a dentist or a physician. I like working with physicians most of the time. Some of them are wicked smart. Some of them give me nightmares. Physicians and Nurse Practitioners vary in their skills. In the best practices, we compliment each other wonderfully.

Sometimes I have stayed hours after work trying to clean up the messes that happen with that physician that sees 70 patients in a five hours. I have also been blessed to be mentored by one of the most brilliant minds in primary care- a virtual Dr. House but with a down home country charm. I think that there isn’t a typical provider. We all vary in our skills and our interests. I don’t see this as a competition in the way that you seem to see this.

I have also seen disrespect on both sides of this debate. I have heard from many Nurse Practitioners who quote all those studies on how patients prefer nurse practitioners over physicians for primary care. I think patients prefer someone who listens to them and who spends time with them. Early in this profession we were given longer visits and were able to focus on our strong patient education skills. Those days are gone. I am often dropped into a primary or internal medicine practice with the same short time slot for complex patients as my physician colleagues are. I imagine those numbers will level out  as we are all pressed to manage complex patients in 10-15 minute visit.

I have heard nurse practitioners complain about the patriarchal “medical” model as if it were completely archaic. Yet,when I was a floor nurse I was blessed to work in a teaching hospital where everyone focused on the whole patient. It was their mission-to make man whole. It was rare to find a physician that wasn’t educated using a more holistic model that focused on health, education, nutrition, exercise and spirituality. None of those stereo types held true. We worked as a respectful team to focus on helping our patients. I respect the role that each of us plays in health care. I am aware of the differences in our education and our skills. I have no desire to practice outside of my scope of practice.

So, Dr. Crankypants, I am so sorry this is hard for you. I think I can understand how unfair it must seem to you that you struggled for so many years in medical school, internship, residency, fellowship and when you entered practice so sleep deprived and drowning in debt only to find yourself shoulder to shoulder with a nurse practitioner managing that same “non-compliant” patient with diabetes. I guess what I don’t understand is why you don’t enjoy the opportunity to teach- to help fill in those gaps where needed. Sometimes I can teach you that the “non compliant” patient isn’t using the insulin because they are afraid of needles and I can help with that. I can teach you that Mary doesn’t need more medication when her blood pressure is out of control, she needs you to know that her husband left her, her son has been arrested and she is working two jobs to make ends meet and forgets to take her medication. I taught her 3 great ways to remember, downloaded that relaxing song “Weightless” to her smart phone and that blood pressure is just fine now.

Dr. Crankypants, you are putting yourself at a much higher risk of an adverse cardio vascular event carrying on with all that anger and resentment. We aren’t going away. Your own health would be improved by finding ways to accept that this is the way healthcare is heading and do what you can to make things enjoyable at work. You could set up in-services at your workplace to decrease what you perceive are unnecessary referrals and diagnostic studies. The sheer number of your posts on this topic leads me to believe that you have an expertise in this area. I want to learn everything that I can. I promise I would buy your book or read your journal submission on this topic. You could offer a podcast or a iTunes University course on when to consult. You could be an editor on UpToDate because Gawd knows I rely on that data base ( as do many physicians) to guide my decision making. You tell us often how that classes on embryology and advanced chemistry make you a better provider and that my empty little head cannot comprehend a fraction of what you know about the workings of the human at the cellular level. You could write a medical sciences for Dummies book! I would read that. Well, no, I probably wouldn’t because I haven’t needed to consult one my dust gathering science text books even once since I started practice.

Some nurse practitioners should not be able to practice independently. Neither should some physicians. Most of us of pretty good at what we do even when it is so hard and overwhelming working in the front line trenches. We need to stop the bickering and work in collaboration.  We need to find solutions to the problems we are all struggling with in healthcare. In the words of Rodney King : … Please, we can get along here. We all can get along. I mean, we’re all stuck here for a while. Let’s try to work it out. Let’s try to beat it. Let’s try to beat it. Let’s try to work it out.

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