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But when I became a physician, I put away nursing things

July 9, 2006 -- Today The Houston Chronicle's business section featured an article by Brett Brune headlined "In-store clinics not a cure-all, doctors warn." The piece describes the American Medical Association's continued efforts to denigrate nurse practitioners and limit the rapid expansion of the "quick clinics" they staff in retail stores. Of course, this is nothing new. The Center has long sought to engage the physician lobbying group on its anti-NP campaign, which ignores extensive research demonstrating the high quality of NP care, and thus appears to be based more on fear of competition than a concern for safety. But the AMA has found a new point person to make its pitch: AMA board member Dr. Rebecca Patchin. Patchin exploits her status as a "former nurse" to bolster misleading attacks on NP training and care that appear in many recent press pieces, including a June 12 Chicago Tribune piece and an April 28 Bloomberg News piece. The AMA's strategy resembles that of an organization that, faced with a strong discrimination claim, chooses someone from the claimant's group to lead its defense. The Chronicle piece balances the baseless criticism of Patchin and a Texas physician only with reaction from the RediClinic CEO, whose brief quote does nothing to defend the quality of NP care. There is no hint that NPs provide comprehensive primary care outside of the quick clinics. And no NP is consulted for the piece, suggesting that physicians are the only health experts with anything useful to say about NP care.

The Chronicle piece's theme is that physicians "warn that the stored-based clinics have their limits." Dr. Michael Speer, of the Texas Medical Association, allows that the idea of the clinics has "some degree of merit" for things like flu shots, simple abrasions, colds, and other "minor illnesses." But he suggests that (in the reporter's words) "if stitches are needed or a cough gets deeper, it's time to go to a doctor." Speer is especially concerned about kids at the quick clinics: "Unless someone is trained in pediatrics, they may miss major things, and the family goes home and feels reassured when they shouldn't." These comments--which relate mainly to the nature of NPs, rather than the inherent limits of this practice setting--will suggest to most readers that NPs are not trained in pediatrics, that they can't do stitches, and that they can't diagnose serious conditions. All of that is false. Speer also expresses the AMA's concern for "continuity of care," suggesting that people who visit the clinics forget to tell their "primary care doctor" that they did so. Of course, the equating of primary care and "doctors" is ubiquitous in the media. But it's worth noting in a piece specifically about NPs, who provide so much high quality primary care.

The piece then notes that the Houston companies "pursuing so-called convenient care" have made efforts to "address the communication issue," though it does not say what those are. It does consult Web Golinkin, the CEO of Houston's InterFit Health, which evidently runs RediClinic. Golinkin says that more than half of RediClinic's customers don't have any primary care provider. That not only undercuts the AMA's professed concern about continuity of care, but also suggests that the clinics are filling at least a small part of the huge gap left by the lack of universal care in the United States--a subject that the AMA does not appear to be so eager to address as it does the supposed dangers of retail store clinics. Golinkin also says that RediClinic customers are discouraged from making it their "medical home" for anything other than "routine episodic care." That's sensible, and we agree that quick clinics (like all health providers) should be clear about their scope of care. But this comment does nothing to tell people that NPs are skilled professionals who are fully capable of providing a "home" for comprehensive primary care in a setting that allows for it.

The piece's main source on the subject of NP skill is Dr. Patchin, who it notes is a "pain management specialist," a "member of the AMA board," and a "former nurse." Patchin says the AMA wants

to make sure the public understands when it's appropriate to use a store-based clinic and when they should utilize an emergency room or a doctor's office ...   When I was a nurse, I didn't know as much as I know now.   ...   The extra years of training as a physician provide added experience, exposure and depth of knowledge regarding patients, illness, disease process and treatment.

The piece closes with an indirect quote from Patchin, who asserts that (in the piece's words) "[m]edical doctors have at least five more years of education than nurse practitioners."

Since Patchin explicitly makes her professional background an issue, let's take a look at it. It appears that Patchin spent 11 years as a critical care nurse before attending Loma Linda University Medical School in Loma Linda, CA, where she now teaches. She practices at the University's Medical Center and other local hospitals. Patchin is an anesthesiologist, a medical specialty that has seen increasing competition from the certified registered nurse anesthetists who now provide most anesthesia given in the U.S., at a level of expertise that is comparable to that of physicians. Patchin's extensive AMA biography makes no mention of her 11 years as a nurse, but it makes clear that she is no mere token choice for the anti-NP campaign. On the contrary, the AMA piece and a number of Internet items suggest that Patchin is an experienced advocate for physicians' financial and legislative policy interests. However, her background as a nurse is almost never mentioned. The reason that background is mentioned in every piece in which we've seen Patchin's anti-nurse quotes appear is, we assume, that she stresses to each reporter that she is a nurse. So when she says NPs are dangerously inadequate for primary care, she seems to know what she's talking about.

Perhaps reflecting her legislative experience, Patchin's media statements on NPs seem to be carefully crafted so that a defense can be made for them--they can be interpreted so that they are not provably false. But they are so misleading that they are almost certain to leave most readers with a highly damaging misimpression about NP training, scope of care, and quality of care, an impression that damages public health. Extensive research shows that NP care is at least as good as that provided by physicians. In particular, contrary to the suggestion of Patchin and the piece that relies on her, NPs themselves provide comprehensive, high-quality primary care, in many cases to the same underserved, uninsured populations who visit quick clinics--a population that obviously is not getting all the care it needs from EDs or "doctor's offices."

If we analyze Patchin's assertion about "five more years of education" the way most readers will likely understand it, as a statement about formal education, then it is simply false. Physicians in the U.S. generally get eight years of university training. NPs typically get six, but many get up to 10, but many get more with post-doctoral fellowships. At most, this is a two-year difference, and one that the research on the quality of NP care suggests is not significant. Incidentally, a large body of research has found that the care of certified registered nurse anesthetists is comparable to that of physician anesthesiologists.

Of course, Patchin surely chose her five-year figure to reflect the fact that U.S. physicians typically undertake paid hospital residencies of three years or more following their graduation from medical school. Therefore, Patchin would doubtless argue, physicians get two more years of graduate school plus at least three of residency, so that makes five more than NPs. But this assumes that the first years of professional practice constitute "education" for physicians but not for nurses. Of course physician residencies are intense, formal affairs, and we wish that NPs did have the benefit of the resources that are lavished on physicians. But in any challenging profession, the first years of practice will be ones of enormous learning, whether termed "education" or not. Physician residencies do not typically have significant classroom components. Moreover, many NPs have years or even decades of experience as bedside nurses before they even become NPs, giving them a tremendous advantage over a junior physician who has never practiced. The real message Patchin seems to be sending is that NPs don't really learn after graduation, because they're just nurses.

Patchin's claim that she "knew less" as a nurse is also highly misleading. It appears that Patchin never was an advanced practice nurse, so she did not have the two to six additional years of graduate education that NPs receive. Patchin did count that NP education in giving her five-year comparison figure, so she must find it relevant, and we see no principled reason for her to ignore it here. Of course, she does "know more" now in the sense that anyone with both nurse and physician knowledge will know more than a person with only one type of training.

Even taking Patchin's knowledge statements on their own terms, it is not clear that registered nurses know significantly less about health care than physicians, and this is so even if the amount of formal university health training is the only measure. RNs typically receive 3-4 years of intense college-level training in health care. U.S. physicians take science and liberal arts prerequisites in college, then receive four years of rigorous health training in medical school. Of course, because U.S. physicians do have more years at university, and because of the boundless social esteem physicians enjoy for the types of knowledge on which many of them focus (see, e.g., Fox's "House"), it's not hard to sell the idea that physicians know more.

But even if nurses or NPs "knew less" in the sense of having memorized a smaller quantity of textbook material, that is not all that matters when it comes to actual primary care practice. The research Dr. Patchin fails to mention shows that practicing NPs provide care that is at least as good as that of physicians. How can that be? Well, would U.S. physicians necessarily be better with 10 or 20 years of formal education? Physicians in the U.K. apparently get five years after secondary school (high school). In any profession there is some point at which more formal education is not going to add tremendously to professional skill. Other factors in quality of care include the ability to see the big health picture, to have a good sense of your scope of practice, to emphasize prevention and health maintenance, and to listen to colleagues and patients, which can mean sacrificing ego and revenue. These are some of the merits of the nursing practice model, and it is far from clear that trading them for more years of graduate school would constitute a net gain. Of course, one irony here is that in the coming years a nursing doctorate is slated to become the basic NP practice requirement, which will make Dr. Patchin's credentialist argument even harder (if not impossible) to make.

Dr. Patchin has made similar attacks in other recent articles. For instance, in a June 12, 2006 Chicago Tribune piece on quick clinics, she again identifies herself as a "former nurse," and makes similar claims about NP skill, training, and knowledge. She professes concern about patients who "have a more serious disease that would not be initially diagnosed or diagnosed quickly [in the retail clinic]." Of course, there will be limits on the diagnostic ability of anyone staffing a quick clinic, but Patchin is clearly linking the problem to the NPs. The repeated focus on this issue will strike many NPs as comical, given how skilled NPs are at diagnosing non-obvious conditions, which often require time and significant interpersonal skill to detect. In this piece, Patchin reportedly asserts that as a nurse she "did not always know what [she] didn't know," and she claims that (in the piece's words) "physicians can have twice the education and training." The statement about "not knowing what you don't know" suggests that nursing knowledge is merely a subset of physician knowledge; otherwise, there would also be things that physicians "don't know that they don't know." However, although there is obviously overlap, nursing is a distinct autonomous profession with its own knowledge base. Nurses have much relevant knowledge and skill that most physicians do not.

In an April 28, 2006, Bloomberg News piece on NPs' growing role in health care generally, Patchin (right) appears to disapprove of the very existence of NPs: "If folks want to practice medicine, they should go to medical school." The piece refers to Patchin's work in nursing as that of a "basic nurse," which confirms that she was not an NP (and insults RNs). In this piece, Patchin also claims that physicians are (in the piece's words) "better able to diagnose disease." Patchin offers no evidence to support that last claim--available evidence indicates otherwise--but we might also note that diagnosis is of little use to most patients if not accompanied by skilled, comprehensive long-term care (sorry, Dr. House). Dr. Patchin's statement about the need to attend medical school reflects the assumption that physician training is the only way to gain the skills needed for effective primary care, a belief that is plainly unfounded. Ironically, many of the most notable shifts in physician training in recent years have been in the direction of the nursing model described above, as one Columbia University nursing professor recently told us. This professor said that many of her physician colleagues were looking to the nursing school to help them incorporate information on psychosocial health and nutrition into medical education.

Normally, we object when the media describes someone who no longer practices bedside nursing as an "ex-nurse" or "former nurse." It tends to suggest that nursing is simply a job that one might do part-time in high school and leave forever, rather than a serious professional career. By contrast, it is unlikely that anyone would describe someone as a "former physician" unless she actually lost her license, perhaps for failing to base her medical advice on current health research. However, we're happy to make an exception for someone who so convincingly renounces her former profession. Dr. Patchin, we couldn't agree more: you are a former nurse.

See the article, "In-store clinics not a cure-all, doctors warn" from the July 8, 2006 Houston Chronicle. Also see a similar article, "Clinics in stores and supermarkets didn't exist a few years ago, but it didn't take long for their founders to begin thinking big", also by Brett Brune, appears in the following day's Houston Chronicle (July 9, 2006). Send your comments to Brett Brune at brett.brune@chron.com.

We have closed our letter-writing campaign on this issue.

 

 

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