Friday, May 17, 2013
QD: News Every Day--Doctors, nurse practitioners work together as they fight over scope of practice
Physicians and nurse practitioners may frequently work together, but they don't get along when it comes to scope of practice issues. The long-simmering feud now has some data meant to fuel discussion rather than inflame rhetoric, study authors concluded.
Researchers conducted mailed survey of 505 physicians and 467 nurse practitioners in primary care from November 2011 to April 2012, (response rate, 61.2%) asking about scope of work, practice characteristics, and attitudes about expanding the role of nurse practitioners. Results appeared in the May 16 issue of the New England Journal of Medicine
In describing their clinical practices, physicians reported working longer hours, seeing more patients, and earning higher incomes than nurse practitioners. A total of 80.9% of nurse practitioners reported working in a practice with a physician, compared to 41.4% of physicians who reported working with a nurse practitioner.
Further highlighting the gap in proper scope of practice, nurse practitioners were more likely than physicians to believe that they should lead medical homes(17.2% of physicians vs. 82.2% of nurse practitioners) or should be paid equally for providing the same services (3.8% of physicians vs. 64.3% of nurse practitioners).
When asked whether they agreed that physicians provide a higher-quality examination and consultation than do nurse practitioners, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed. Another difference: 88.9% of physicians in collaborative practice agreed that "nurse practitioners typically defer certain types of patient care services and procedures to the primary care physician," compared to 61.3% of nurse practitioners (P less than 0.001).
Researchers noted that primary care physicians are unlikely to embrace expanding the role of nurse practitioners for fears of health care quality. This stems in part because "nurse practitioners and physicians come from very different cultures of professional education, are guided by different theoretical perspectives, and often develop their clinical skills in different practice environments."
Authors wrote, "Both physicians and nurse practitioners will be needed to address the many challenges of developing a workforce that is adequate to meet the need for primary care services. It is our hope that the stark contrasts in attitudes that this survey reveals will not further inflame the rhetoric that has been offered by some leaders of the two professions but rather will contribute to thoughtful solutions for health care workforce planning and policy."
In an editorial, David Blumenthal, MD, FACP, president of The Commonwealth Fund, wrote that the feuding comes amid an increasing primary care shortage. Nurse practitioner provider the same quality of care with better scores on patient communication, yet complex-disease care remains unanswered and patient preferences about who provides care need to be considered.
Dr. Blumenthal highlighted four points to consider in future policy talks:
--Objectively interpreted data on the differing competencies of these two types of clinicians should guide policy, "not rigid, often antiquated state laws";
--Policy should be flexible as studies increase understanding of physicians and nurse practitioners' roles;
--Patients should have a larger say in who provides their care; and
--There must be higher priority given to developing the primary care workforce.
He wrote, "[U]nless physicians and nurse practitioners collaborate to improve primary care, neither will be happy with the outcome. We urgently need a facilitated, open dialogue about the roles of physicians and nurse practitioners that includes representatives of the public."
The Sydney Morning Herald is reporting that three patients in two Sydney hospitals have developed listeriosis after consuming profiteroles served to patients at the hospitals. The infecting strain in all patients was identical. One of the patients has died from an apparently unrelated cause.
Nosocomial foodborne illnesses, particularly those of bacterial origin, are seemingly uncommon. I suspect this is likely due to a lack of appetite in many hospitalized patients, and the highly processed nature of hospital foods. (Sometimes I'm not sure it's actually food).
A few weeks ago, while making morning rounds on the inpatient infectious diseases consult service, I went to see an immunosuppressed patient with pneumonia. As I was about to leave his room, I noted a clear plastic container of macaroni salad on his overbed table that had been served the evening before. My paranoia of foodborne infections must have been palpable. He thought it was quite funny that I alarmingly said, "Don't eat that!" While laughing at me, he said, "That's old Doc, I'm not gonna eat that." Just to be sure, I threw it in the garbage, which made him laugh all the more.
Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Thursday, May 16, 2013
Means, at the ends of ethics
Doctors, psychologists, ethicists and others, along with our society at large, debate whether "the ends justify the means." But nobody debates whether "the means justify the ends." There is no point even looking for an answer to a question that is patently silly. For now, just hold that thought, please.
Medical ethics can be very challenging. There are the difficulties of interpreting "do everything" in desperate situations where heroic effort is on one side of a line, and futility on the other. There are the challenges of doing "no harm," while taking great risks. There are challenges of optimal resource allocations for the greater good. There are challenges related to tradeoffs between beneficial and adverse effects, particularly with high-risk surgical and critical care procedures. In this context, the question of ends justifying means comes up routinely.
Perhaps the most vivid and obvious illustration is any variation on the theme of euthanasia. Those who believe it is the work of medical practice to protect life view all such variants as wrong, if not anathema. If, however, the work of medicine is to preserve dignity, and autonomy -- the case for assisted dying can be made, at least under narrowly-defined circumstances. It can be a case where the ends--relief from suffering, death with dignity--might justify the means.
The question has far-ranging implications for the whole field of ethics. One school of thought, for example, is that whatever achieves the greatest good for the greatest number is "right." This is referred to as utilitarianism, and while few real-world ethicists espouse it in pure form, they do invoke its principles.
The extreme contrary view, deontology, stipulates that some things are wrong just because they are wrong, no matter what effects they exert. Again, the pure practice of this probably doesn't exist, but it informs the "do ends justify the means" debate.
Psychology experiments famously reframe the "ends versus means" debate by presenting a scenario where a great deal of good can be done, such as saving a whole group of people, but only by doing intentional harm, such as killing an individual.
There are good reasons why the debate endures, and is to some extent insoluble. There may be no single right answer.
But again, no one wrestles with the reciprocal question, "Do the means justify the ends," and with good reason. If you are getting bad outcomes, what point could there possibly be in "justifying" the means that lead to the ends you don't want?
In a world where means are used to justify ends, there might be means to treat the nausea of pregnancy. For those affected by it, those would be welcome means, indeed. And for those with more severe forms of pregnancy-related nausea and vomiting, they might even be truly important means.
But, as has in fact proven true in the past, those means might produce serious unintended consequences, in the form of birth defects. In a world that sensibly asks "do ends justify means?" while just as sensibly avoiding "do means justify ends?" the response to this is rather obvious. Doing what seems like a good idea stops being a good idea when it produces bad outcomes. A treatment for pregnancy-related nausea that produces common, serious birth defects would not be justifiable. The abandonment of thalidomide for this purpose demonstrates that this is not just hypothetical. In the real world, bad ends unjustify well-intended means.
And now we come to the reason for this ramble. My hope, if not quite my belief, is that we might constructively look at the vexing issue of gun control through this same lens. We do so, of course, in the immediate aftermath of background checks failing to make it through the Senate.
The roiling debate about the Second Amendment seems to hinge on where one places one's semantic emphasis. Those opposed to any regulation of gun sales emphasize "shall not be infringed." Proponents of gun control emphasize the subordination of that clause to "a well regulated Militia."
I have opinions about this, and you may as well, but since we are unlikely to resolve any differences of opinion about the language of the amendment here and now, let's not try.
Rather, let's consider this: The language of the amendment, however it is interpreted, is about means. Some manner of access to guns for some portion of the citizenry is the means, and something like defense against tyranny and protection of liberty the presumably intended ends.
Clearly, the ends could justify the means. If more guns of all kinds freely accessible to all meant more liberty, more security, less risk of tyranny, then the means might well be justified, and the fuss would end.
But the means cannot justify bad ends. If the consequences of interpreting the Founders' means one way are ill and unintended, such as the massacre of schoolchildren without better protection of liberty of defense against tyrrany, then the means, whatever their original intentions, are subject to reconsideration, no less than thalidomide. It in no way tramples the rights of pregnant women to have their nausea treated when we abandon a drug that causes birth defects. Bad ends, however unintended, unjustify means, however well-intended.
We might better confront the gun control debate with data, gathered in a non-partisan manner, about the ends we are getting. We could make a systematic effort to look for all potential good, and all potential bad, ensuing from the status quo just propagated on the floors of the U.S. Senate. If we don't even look for such data, it implies someone doesn't want to know the ends we are getting, and that is an always ominous sign of ulterior motives and cowardice. We must know the effects of our actions to be qualified judges of our conduct.
Whether ends justify means will remain, in particular contexts, a legitimate and challenging debate for the foreseeable future. But in a world where means justify ends, and unintended consequences don't matter, the very concept of ethics has met a very mean end already.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Influenza at the human-animal interface
The first three novel avian influenza A (H7N9) viruses have been sequenced, and the sequences uploaded to the Global Initiative on Sharing All Influenza Data (GISAID). Not surprisingly, there were genetic changes found that have been associated with increased transmissibility of other avian flu strains to mammals.
I have no deep thoughts on this--it is what influenza does, after all, with avian and other non-human strains occasionally making the leap to humans. The few things we know about this particular strain, as of late yesterday, can be found at the CDC and WHO websites, and include the following:
--A total of 21 cases have been laboratory confirmed in China, including six deaths, 12 severe cases and three mild cases.
--More than 530 close contacts of the confirmed cases are being closely monitored.
--The viruses isolated to this point appear to be susceptible to neuraminidase inhibitors (e.g. oseltamivir) but resistant to adamantanes (e.g. amantidine, rimantadine).
--There is no current evidence of "ongoing human-to-human transmission."
--The virus should be detectable with existing PCR methods as an "unsubtypeable" influenza A virus (the CDC is working on adding this strain to their testing approach so that it can be more quickly subtyped if it spreads outside of China).
The most recent interim guidance for case investigation, testing, infection control and treatment are here.
Finally, for those interested in a regular update on the threat of non-human flu strains, the WHO publishes monthly updates on influenza at the human-animal interface. (Wait, aren't Homo sapiens also animals? Maybe it should be, "influenza at the human-nonhuman interface" ...)
Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.