Nurse practitioners not actually TEOTWAWKI* – yay!

A page from a calendar for November 2010 - "TEOTWAWKI" is written over it in bright red slanted letters*TEOTWAWKI – The End Of The World As We Know It

Australians know the difference between being sick and needing a doctor and those “everyday health concerns” when a nurse practitioner would suffice, preliminary research shows.

The Australian Primary Health Care Research Institute (APHCRI) says its research shows Australians were comfortable with the newly expanded role to be taken on by specially trained nurses.

Hey, that might just be because lots of Australians think it’s blindingly obvious that the AMA’s long opposition to nurse practitioners has always been about gatekeeping GPs’ monopoly on primary health care instead of about providing Australians with the best possible healthcare services mix? As in about bloody time we took this highly sensible step to more efficiently enable wider and more timely access to well-trained health professionals?

Apparently, “an online poll was underway to further gauge public opinion on the changes” and it can be accessed at surveymonkey. Please, for Maude’s sake, go there and add your voice to the enthusiastically endorsing side of the column so that perhaps future coverage of the essential role about to be filled by nurse practitioners won’t be reported in such condescending terms in future.



Categories: ethics & philosophy, health

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31 replies

  1. Back in NZ, I saw nurse practitioners for smear tests, and my children’s vaccinations, but I’d be happy to see them for a range of other issues too (eg. minor injuries, “flu”, repeat prescriptions, contraceptive advice, wound care, blood tests, and there’s probably more that I can’t think of right now).

  2. As our local hospital is often without a doctor, our nurse practitioners are quite busy. If we didn’t have them we would have extremely stressed and distressed ambulance officers trying to get to the nearest big hospitals close to an hour away and probably a few people who would not now be with us. There are lots of things that nurse practitioners can do, and often do do in Drs surgeries so I have no problem with more of them being available in hospitals. Most of my visits to the emergency ward [thank the FSM] have been for minor things easily dealt with by the nurses, and mostly involved calming me down while something small was done for my child. We need more of them, especially if we can’t get more doctors. Nurse practitioners are often the only people available in rural areas.

  3. Pharmacists are all up in arms about it too (though not as much as doctors) but honestly I think nurse practitioner and midwife prescribing is an awesome idea and will expand healthcare access. If the AMA didn’t want this to happen, they should have made sure that doctors were available to cover the areas where their services are needed, not concentrated in wealthier suburbs of major cities. They didn’t do that, and the government has responded appropriately in its role as a health administrator by increasing accessibility.
    I find it absolutely hilarious (in a dark sort of way) that the AMA complains that people will be inappropriately treated by allied health and major diagnoses will be missed. I spent 18 months with cancer, missed by many doctors when a simple blood test would have shown something wrong – and diagnosed with a problem in 10 minutes flat by an audiologist I was seeing for a condition that turned out to be only marginally related. No-one is perfect, and seeing a range of medical staff is a very, very good thing.

  4. I would honestly prefer to see a nurse practitioner in most instances. I find the demeanour of most GPs incredibly off-putting and often procrastinate about making an appointment. I have rarely met a GP that I would be happy to see a second time and when I do they have usual moved on by the time I need to see them again.

  5. I’m checking out the survey. One question I find difficult to answer: “Please tick if you would be happy to see a nurse practitioner for any of the following options in your general practice:” – with a range of diagnoses/presentations/tasks.
    In actual fact, I wouldn’t necessarily “be happy to” see a nurse practitioner in my local general practice for a simple URTI or minor soft tissue strain, because I wouldn’t see one for those things, and it would be a waste of everybody’s time and money for me to do so. I also wouldn’t “be happy to” see a NP for emergency contraception, because that should be over the counter at a pharmacy. But I’m guessing I have to say “yes”, because they’re interpreting a “no” as “No, I would want to see a REAL doctor”. Would I be happy for other people to see a NP for those things? Sure.
    And the answer to a whole lot of the other options is “it depends”. Would I be happy for an NP to order and interpret X-rays and other radiological tests? Mmmmmaybe. I would be happy for one to order an ankle xray for a possible fracture, but not to completely manage and sign off on radiological investigations of a new breast lump, abdominal mass, or complex neurological symptoms.
    Would I be happy for a NP to “manage chronic or continuing condition”? Completely, or in collaboration? NPs have huge roles to play in the management of, say, diabetes or asthma or arthritis. Nurses are already playing these roles. But does “manage” mean the person never ever sees a doctor?
    I’m also antsy about them putting “cough” and “flu” in with “cold” under “minor infectious illnesses” – flu is often a damn serious infectious illness, and a cough can be anything from a cold to asthma to lung cancer or life-threatening airways disease.
    On this page there needs to be an “it depends” or “sometimes” option, and the opportunity for text entry.

  6. Mmm, re Lauredhel’s concerns I’d be (fairly obviously) most happy seeing an NP with a clear scope of practice and good fast access to a GP and/or specialist medical referrals. A bad scenario, for example, might be NPs going into practice and then it’s suddenly acceptable for GP availability to drop and to need to wait three weeks/months if either I or the NP decide a GP’s opinion is needed or care needs to be handed over. I have friends in the US who have been in that situation.
    For that matter, care being handed over is a tricky thing. I found the pregnancy model in which care is fully handed over from midwives to doctors for some patients somewhat distressing, because the division had only encouraged the doctors to believe that whole-patient (whole-pregnancy) care wasn’t their province at all, which left me as a doctor’s patient at sea with many things. It hopefully would not be the case that GPs hand over all the “touchy-feely stuff” to NPs and then leave regular GP patients (so, sicker people by and large) without that relationship. Also would there be this system of doctors being able to say “OK, now you’re not an NP patient at all, say goodbye NP-you-got-on-with because now your care is mine”? Hopefully not, or at least not unilaterally and at short notice.
    Disclaimer: I realise I am idealising current GP care quite a lot here, but some people are lucky enough to have long term quality medical care from a single or small number of GPs who they like and respect. It would be terrible if that came to disappear even as an ideal.

  7. @lauredhel I had similar problems with the survey, and also got stuck on the question of whether I’d be happy to see a NP if there was a cost to me. My GP bulk bills so no, I wouldn’t be happy to pay extra, but I know perfectly well that’s not what the question means. More nuance needed.

  8. If the AMA didn’t want this to happen, they should have made sure that doctors were available to cover the areas where their services are needed, not concentrated in wealthier suburbs of major cities.

    I disagree that it’s the responsibility of the AMA to do this. If we all think it’s important for everyone to have better access to doctors (or any medical attention), we should provide incentives for this (via the government) or find a way to equalise access. How, exactly, should the AMA do this?
    Do remember that the AMA are composed of (and represent) actual human beings who, like you, have legitimate concerns beyond the balance of their bank account. I’m certainly not saying their arguments are above criticism — nobody’s are — but namecalling isn’t really criticism. There are valid reasons for controlling the dispensation of medical advice and attention, and for resisting changes to this system of control… especially when we know from experience that what might seem like a good way to broaden access to something can (but not necessarily will) turn into a stopgap which makes people defer seeking more specialised attention.
    (…and also remember that it is possible, through repeated reinforcement, to create a highly adversarial culture where people are judged simply for seeking access, leading to a tiered system enforced not through bureaucracy or policy, but through this culture. For example: vaccination.)

  9. I don’t see how “the AMA is concentrated in wealthier areas” and “if they are concerned about access, they should promote access” is “name-calling”. I certainly don’t think it’s solely the AMA’s responsibility at all.
    There are valid reasons for controlling the practice of medicine, but “no-one else but doctors should do it” is hardly a nuanced response. I refer in particular to Dr Rosa Capolingua’s comments that people will necessarily be missing out on appropriate referrals and treatments if they see allied health practioners such as audiologists or nurse practitioners rather than doctors, and the AMAs war against independent midwives is well documented on this blog.
    I’m not sure what you mean by your last paragraph, so I can’t comment on that.

  10. The namecalling referred to the “gatekeeper” remark in the post itself, not your comment (and to a lesser extent, casting the AMA as doomsayers). Sorry for not delineating that.

    I’m not sure what you mean by your last paragraph, so I can’t comment on that.

    Well, take this:

    the AMAs war against independent midwives

    It’s not a war, it’s a debate. In an actual war, people have to pretty much pick a side or be branded as traitors, and your use of that figure of speech is my point. Yes, the real point is that “if someone wants to see an NP or midwife, they should be able to, and if someone wants to see a doctor or go to a hospital, they should be able to.” But if you convince people that it’s a “war”, even someone who probably should go to a doctor is going to feel like a traitor.

  11. I can’t remember what my original wording was, but I actually ended up redacting it to “gatekeeping” as less inflammatory language. It’s interesting that you see that as so insulting.
    To an extent, gatekeeping the practise of medicine is part of what the AMA is for, and so it should be, but I’m not alone in opining that their reaction to both the expansion of the nurse practitioner role in primary health care and the role of independent midwives has frequently been arrogant and supercilious, and hardly devoid of fearmongering about both groups’ qualifications for practising without physician supervision either.
    However, it’s not especially the AMA’s role to ensure that there is an adequate supply of GPs practising outside comfortable metropolitan abodes – that’s a Health Department matter to provide incentives to counter the perceived drawbacks of practising in such areas. Sadly, since that would probably be most effectively done by rolling back some of the policies which have led to the shrinkage of viable local economies in rural areas over the last few decades – when country towns were thriving, there were plenty of GPs who were happy to practise in them – it’s probably not going to happen.

  12. However, it’s not especially the AMA’s role to ensure that there is an adequate supply of GPs practising outside comfortable metropolitan abodes
    No, but in that case the AMA should not take on the gatekeeper role in those communities without doctors – my town had no regular doctors and often no doctors at all for two-and-a-half years, for example. We’re not particularly remote, have a thriving economy and a young and growing population and many amenities. Nurse Practitioners are a terrific solution for many places (including some suburbs) and should be encouraged by the AMA at least as a doctor substitute. It would certainly give them the appearance of co-operation rather than turf-guarding!

  13. I don’t agree that it is only a debate between the AMA and independent midwives. The AMA have used spurious statistics to stop independent midwives practising and helping women homebirth. That is more than a debate. They have clearly taken a side and forced independent midwives out. /end threadjack.

  14. It’s interesting that you see that as so insulting.

    I don’t see it as particularly insulting (ahem, I never even used the word…). I just think there’s a lot more to it than ”gatekeeping GPs’ monopoly on primary health care instead of about providing Australians with the best possible healthcare services mix.” To start with, maybe they think that gatekeeping is providing the best possible healthcare service.
    Look, at no point have I defended the AMA, at no point have I said they’re absolutely right about this, at no point have I in anyway disagreed with idea behind this post. I will be the first to admit that I don’t know enough to wade in on the details. But you’re reducing what I think are at least valid ethical grounds for objection to some silly caricature. When people to that to feminists, I get annoyed. When people do it to scientists, I get annoyed. When people do it to doctors, I get annoyed.
    (I don’t expect you to come out swinging for the AMA either, or give their arguments a stage on your blog, or blow it out to several paragraphs with heavy qualification. I’m just saying, it must be possible to say something pithy or flippant without being as derisive as them.)

    I don’t agree that it is only a debate between the AMA and independent midwives. The AMA have used spurious statistics to stop independent midwives practising and helping women homebirth.

    And occasionally representatives of the ACM have used essentialist arguments on their side (I think that’s the term, anyway). So what? Even if it’s a dirty, heavily politicised verbal mud slinging match, even if the AMA really do value membership fees over public health, it’s still not a war.

  15. You can say “mud-slinging match” but “war” is too literal for you? I will retract “war”, then, and substitute “bullying” to avoid a terminology debate.
    To start with, maybe they think that gatekeeping is providing the best possible healthcare service.
    Maybe they do, and would probably argue that. I disagree strongly and it seems that evidence on nurse practitioners gained from the limited number of nurse practitioners already in play (as specialised wound care experts, for example) and from overseas data would indicate that the AMA’s stance is wrong, limiting and a power play based on already being in a gatekeeper role that they wish to maintain.
    I don’t think they’re evil incarnate, I realise they’re people (and number a few AMA members among my friends) but as far as I can tell, you’re trying to argue that supporters of nurse practitioners and/or critics of the AMA should be quiet and agree that the AMA might have some good points. Which they might. But I’d like to actually see them before agreeing that there are problems with the nurse practitioner program.

  16. Jason, I think you’re misunderstanding the term “gatekeeper”. It’s not remotely name-calling; it’s a neutral, non-derogatory term used routinely by various parties in discussions about first contact and referral control in health care.
    The term is used by the AMA in their formal policy documents:
    Position Statement: Primary Health Care – 2010

    ”Australian general practice is central to our primary health care system and provides the point of access for patients into the system. General practice must remain the gatekeeper to secondary medical care, ensuring an economically sustainable, high quality health system. “

  17. I think we have different ideas of what a war is. I don’t know too many people who have lost their livelihoods in a debate, or been forced into a hospital to birth where they’ve had previous bad experiences. When the AMA’s actions are aimed squarely at a competing [for a very small number of women] medical service provider then it’s gone beyond a debate and is affecting people’s lives in a very negative and far reaching way. It doesn’t have to physically involve weapons to be a war. Money and influence are extremely effective weapons and the AMA has both of those in spades. Plus like all wars, women are the losers.

  18. Wow, okay. Thanks Lauredhel. I humbly withdraw that objection then. And although I’m still critical of the “instead of” and TEOTWAWKI bits, that’s hardly name-calling, so sorry.
    (Seriously? They call themselves the gatekeepers? Just… wow.)

  19. Mindy — my only point is that there is a difference between saying women should be free to choose how they give birth and the AMA are deliberately obstructing that with dirty tricks and implying that many individual doctors care more about their income than human life. I am not accusing you of the latter, and I am certainly not saying “don’t argue the former in case people hear it as the latter.”
    The only point I’m trying to make is that a million little comments that reduce the AMA to this kind of caricature of themselves may actually do a significant amount of harm in the future, just like it has done with other medical issues in the past. I don’t disagree with the argument, or with the urgency, or with the impact. I disagree with combating the problem by replacing one negative, dismissive, patronising culture with another.

  20. I agree with Lauredhel re the questions. Many of them are: well it depends.
    As somebody who has a long working history in the medical field, many as an RN, I’ve never been able to get my head arround this ‘either/or’ attitude that prevails, particularly within the AMA ranks, in health care and health management issues. Either a nurse or a doctor. It should be both. A NP would know when to refer on to a higher level of care. In fact I’d trust a NP to refer me on to appropriate care before I’d trust many a GP to do the same.
    I have a long standing good relationship with my GP, but I cannot even tell you how many times I’ve been to see the GP when it would have been quicker, easier and cheaper to see the NP and it irritated me boundlessly I couldn’t. I would actually be perfectly happy to see an NP for most things, including initial requests for pathology to then be referred on to a doctor after all the preliminaries. But, I’d say that GP’s might then suddenly find themselves a bit obsolete, as more referrals would occur straight to specialists.
    This is another of my irritations. How many GP’s think they can manage everything without any referral to a specialist. Medicine is a very dynamic area and increasingly specialized.

  21. but as far as I can tell, you’re trying to argue that supporters of nurse practitioners and/or critics of the AMA should be quiet and agree that the AMA might have some good points

    No, that’s pretty much the opposite of what I’m saying, but you seem to be interpreting my quibble with the presentation and tone of an argument as complete opposition to it no matter what I say.

    • Jason, if you find hyperbole as a rhetorical device ^this upsetting then perhaps the Internet is not going to be your friend.

  22. …my quibble with the presentation and tone of an argument
    Yes, because that’s a classic derailing tactic to argue over presentation and tone rather than the argument itself. If you’re not saying that we should shut up and be nice to the AMA because they’re people too (whatever their tactics on this issue) what are you saying?

  23. How many GP’s think they can manage everything without any referral to a specialist.
    I wonder though, how much of this is resistance from patients – I know I managed thyroid issues for a long time just with GPs because it was so expensive and difficult (in travel time, waiting lists, the choice between required blood tests from a particular pathologist 55km away or a large co-pay, and time off work) to see an endocrinologist. While I’m sure that there are GPs who think they can manage everything themselves, many people prefer GP management (and, I suspect, will prefer NP management once a relationship is established, for similar reasons) just for reasons of cost and accessibility.

  24. Yes, because that’s a classic derailing tactic to argue over presentation and tone rather than the argument itself.

    It’s also a classic debate tactic to tar your opponents with a negative stereotype and cast all who agree with them as having some sinister, unstated motivation. And if you throw it in with an actual piece of evidence, when someone says “hang on a sec, about that thing you just said…” you can accuse them of dodging the issue.
    I’m certainly not saying shut up, or be nice — you’re implying that I want to silence the side of this debate that I support, which I do not. What I’m saying is that this tactic creates cultural problems that are easy to dismiss now (as hyperbole, as typical discourse), but actually do have an effect. As Mary points out above, some doctors are now starting to think that there is a class of medical issues that they should treat less than seriously. Is it because these doctors are stupid or impressionable? Or is it because of some nebulous, hard-to-pin-down cultural effect that comes about through some of that negative stereotype and adversarialism actually sticking and being internalised?
    It also works the other way too, where patients or medical professionals will understate symptoms or delay escalating medical attention. It’s not because they’re idiots, or because they’re stubborn, it’s the same invisible baggage that makes them feel like they “should do it this way” and not trust the white coats.
    If the AMA have holes enough in their arguments and tactics, why go that way at all?

  25. Jason, I absolutely agree that dividing people into always-opposed teams is counter-productive and divisive. I just don’t know why you think defending the most powerful medical organisation in Australia and the divisive, all-or-nothing, uncooperative tactics they have been using is a good way to demonstrate that working together produces better results.

  26. I just don’t know why you think defending the most powerful medical organisation in Australia and the divisive, all-or-nothing, uncooperative tactics they have been using…

    And I just don’t know where I’ve done this. The most charitable thing I’ve said about them was that their concerns are actually legitimate, and even that was qualified with “not necessarily correct”.

    • @Jason, you have now ‘splained in great length over many comments why you feel that several aspects of my post were “counterproductive”. I think we’ve all got the message.
      Despite the fact that you may legitimately feel that some of the objections to your comments have misread you, you’re still not actually moving the discussion on by insisting on repeating this.
      I ask everybody to move on, please.

      • I’d like to clarify something about my TEOTWAWKI reference in the headline. It was in regard to the condescending tone of the linked article, i.e. the criticism with which I ended the post. That article’s explication of the poll results seemed to have a tinge of surprise that people were largely positive about independent nurse practitioners, and that’s what got my sarcasm mojo going.

  27. It will be interesting to see what the medicare rebate is for seeing a Nurse Practitioner as opposed to a Dr. It costs me $55 to see a Dr (which I think is probably on the cheaper side, especially compared to Canberra) and I get about $30 of that back. If it costs me $55 to see a nurse and I only get $20 back then eyebrows will be raised. This would also also hobble the program pretty quickly I think. I guess it depends on who sets the pricing.

  28. While I’m generally supportive, I think there’s a lot of detail which will need to be worked out which will affect how well use of Nurse Practioners will work out. Just some random thoughts…
    – What is this going to do wrt fragmentation of patient familiarity/records. I currently go to see the same doctor nearly every time. So she’s pretty familiar with my medical history – if time is split between a NP and a doctor is it more likely that things will get missed?
    – Some people only see a doctor very rarely only when they really really need to (this used to be me). Will NPs be as good as doctor’s at picking up potential problems with a patient which they didn’t come in for (has happened to me) and didn’t realise could be a problem.
    – It will probably be hard for many patients up front to know if the really need to see a NP or doctor. If they get it wrong and need a make a doctor’s appointment will they have to wait yet more days to get time with a doctor? And for those not bulk billed it may end up costing more as they have 2 appointments instead of 1.

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