Thursday, March 19, 2009

Nurse Practitioners: All The Attitude Of A Physician, None Of The Skills.

My friends, this night I will convince you that all Nurse Practitioners should be stripped of their prescribing authority. Actually I won't do it, a Nurse Practitioner who chose to put on public display her incredible ignorance will. All I will do is cut and paste a letter to the editor from the leading trade magazine Drug Topics:

Generics are not the same

I am an NP in pediatrics — old school, you could say — practicing for close to 20 years. I have a real problem with generics for my patients, family, and myself. I was taught and have read that certain generics such as those used in warfarin and cardiac therapy should not be used.

Even the slightest difference could prove harmful. An oncologist here in town will only use brand Coumadin for her patients. I witnessed my father's blood pressure soar after only a few days on a generic and quickly return to normal after he took an extra dose and then went back to brand. I find various generic antidepressants have little to no therapeutic effects on the majority of my patients.

Brand drug prices are soaring. No one really talks about this subject, and consumers, our patients, should know or have a choice!

Jeanne Monaco, BM, BSN, MSN, ARN, CPNP


Dear Jeanne, 

I am a community pharmacist that has practiced for almost 20 years-old school you could say-if you were dumb, because there are about as many people who have practiced longer than me as there are people who haven't been practicing as long. So you could call me old school if you want, but a little mental effort would tell you I am really middle school. 

But the fact you have no sense of time doesn't make you stupid. Well, actually it does, but that wouldn't be a problem if that was where the stupidity ended. The real reason I'm posting here Jeanne, is to let the world know all Nurse Practitioners are incompetent. I have a real problem with Nurse Practitioners for my patients, family, and myself. I was taught and have read that some Nurse Practitioners don't know what the word "bioequivalent" means and should not be used.

I know an oncologist who refuses to let his wife or anyone he cares about see a Nurse Practitioner. And one time, I witnessed a patient who was treated by a Nurse Practitioner, then died. Many other people have died after seeing Nurse Practitioners as well. One other time, a person I know being treated by a Nurse Practitioner went code blue at the hospital, only to quickly return to normal after being attended to by a physician. I find various Nurse Practitioners to have little to no therapeutic effects on the majority of my patients.

The cost to see a physician is soaring. No one really talks about this subject, and consumers, our patients, should know or have a choice!

So there you go Jeanne, I just proved Nurse Practitioners are dangerous and should be avoided. The same way you took down over two decades worth of real world data and scientific evidence regarding generic drugs in 143 words. Or I just pulled a bunch of shit out of my ass, one of the two. Either way, our letters are remarkably similar, yes? 

Something tells me you don't see my point. 

Drugmonkey

ABU, NCH, OFLET, TERS, TOH, IDE, IMAM, ORON

63 comments:

a bunch of letters to hide i'm The Alert Reader said...

THE A-GAME IS SO ON RIGHT NOW.

Abrasive? Yes, sir. And better than Shakespeare.

LB86 said...

That was honestly the best spin on logic that I've ever seen. Drug monkey 1, NP 0.

Frank, CPhT said...

Wow... One of the pharmacists I work with would absolutely love to see this, Mr. Drugmonkey. The pharmacist I work with has been fighting a battle with a nurse practitioner over her prescribing authority. In the state of Ohio (probably other places as well) NPs are unable to write for controlled medications, yet this NP seems to see it in her power to write whatever the hell she wants.

You bring those NPs down, oh mighty Drugmonkey!

Frank, CPhT, NOL, ETT, ER, STO, ST, RIN, GTO, GE, THER :(

Anonymous said...

Damn Drug Monkey I knew there was a reason I keep coming back here, even though I ostensibly hate my job and the entire profession.

That rebuttal kinda got me goin'. Clearly, the drugs are in my blood.

Dragonfly said...

Maybe by old school she meant "before the patent is up"? Except that would be 14 years, not 20.

"Brand drug prices are soaring". Solution = use generics if the option exists.
Though in some cases that might cause prices to rise while still in patent, because Pharma knows that they won't get as much as soon as Acme makes it. I have no problem with pharmaceutical companies being paid fairly for the R&D, otherwise we would still be using unfractionated heparin and aminophylline (yes, I know they are still used in some circumstances). But choice does mean options. And the better option is always going to be bioequivalency at a better price. (Barring any bizarre differences in stabilisers/additives which could cause reactions, but one would hope that these would not make it through quality control).

Anonymous said...

Actually, about a year and a half ago OH NPs began legally writing for controlls (provided they have their own DEA#). Recently, PAs gained prescriptive authority too. Both of these may or may not be good things...

Anonymous said...

This was hysterical - I say you submit the response to Drug Topics! DO IT!!! That'll teach them that they shouldn't publish such trash....oh, I forgot, they are a "throw away" journal. Makes sense...

midwest woman said...

as a nurse, absolutely loved this...nps and pas are the bane of my existence..the only differences I can see is they get to write in the progress notes and their "orders" don't have to be preceded by a verbal or telephone order notation. They do look nice with white lab coats and get to work cushy hours.

midwest woman

FOS, BS, WXYZ
FOS, BS,

Maria said...

The only thing I will say is this:

generics are great and I take them whenever I possibly can. But patients need to be more informed about the fact that, say, bioavalibility of a generic can be +/- 20% of it's brand name counterpart. That *is* a pretty big thing when dealing with a lot of meds. When Lamictal went generic I went absolutely batshit because I was getting so much more of it from the generic. But, see, I'm an EDUCATED consumer, so I was careful and looked out for it and adjusted my dose as necessary.

Anonymous said...

LOL, awesome!!

angrytech said...

good play, kind sir, good play.

annpharm said...

BRAVO!! Your finest work yet!!

Anonymous said...

You just have to ask yourselves why would Drug Topics even print that letter? Unless they wanted the Drug Monkey to submit a response!

Anonymous said...

I don't really have a problem with PA's. They seem to be a lot nicer than the vast majority of MD's, and don't screw up too terribly often. Probably less often than the MD's, actually.

But NP's... wow. I have never met an NP I liked. There is USUALLY something wrong with every NP script I see. And then they're always super nasty when you try to call and tell them that there's no such thing as Amoxicillin 450mg tablets.

Anonymous said...

Better than sending to Drug Topics, look up the NP that wrote the letter on the npi web site and send her a copy! Consider it done Drugmonkey

Anonymous said...

Interesting Fact:
For a generic to be AB Orange book rated, all a generic has to do is match AUC, Tmax, and Cmax of the namebrand on 25 males between the ages of 18-25 years of age. These 25 individuals have perfect functioning GI tracts, livers, and kidneys. I just don't think that's enough people or enough patient variation. Also one generic doesn't have to match another generic for the same namebrand.
-Erin, Pharm D Candidate 2010

Anonymous said...

I was seen a PA for an abscessed tonsil, told I had cold, given Vicodin and told to go home, because the rapid strep test was negative. I had one huge, red tonsil and a high fever. My doctor's office has a completely incompetent PA who thinks CAT scans can rule out appendicitis. Both of them could have killed me. Awesome.

Beloved Parrot said...

First of all, your link to the article isn't working.

Second of all, I know your letter was about nurse practitioners, but I'd like to say for the record that I no longer bother seeing my doctor (who's far too busy to see patients anyway); I get all my medical needs taken care of by her physician assistant. This PA knows more than the doctor, knows her way around drugs better than some pharmacists (!), and has actually taken the time to speak more than ten words to me.

I can't speak for nurse practitioners, but I'd be lost without my physician assistant.

Anonymous said...

"I find various generic antidepressants have little to no therapeutic effects on the majority of my patients."

Every once in a while I get a patient asking about brand vs generic. The one thing I say to them is that the Brand and Generic use the same chemical compound to get the job done. It would be like picking one generic manufacturer over another; neither one has a magical machine that makes it any better than the other!

Frantic Pharmacist said...

You absolutely must submit this to Drug Topics! Brilliant, as always.

Phrustrated Pharmacist said...

Maria said...
The only thing I will say is this:
I went absolutely batshit...

The only thing worse than a Nurse Practitioner is an "educated consumer." Sweets, I hate to break it to ya, but that +/- 20% is overall, not either side of par. Good luck with adjusting your own dose, though. Last time I checked, "going batshit" was not listed in the side effects of lamotrigine.

DM, keep up the drubbing of NPs, that's quality reading after a long day.

Anonymous said...

So much for evidence-based medicine. I have no use for NPs. I am sick of having to fax them to correct their prescriptions since I as a pharmacist in Ontario can not modify a their constant mistakes.

Ellen said...

One NP who is a complete and total idiot - and who deserved the beautiful pwning you've just delivered - is not equivalent to all NPs.

Loved the evisceration of this bimbo.

But I'm disappointed otherwise.

I know some excellent NPs. But I'm in a rural area. Our NPs practice independently. Perhaps I see a higher caliber.
I know some rather dim physicians.

Regardless, ANP Monaco is kind of an idiot. An AB-rated idiot.

Anonymous said...

Ear zits hurt like a mofo

Maria said...

Phrustrated Pharmacist:

So, patients should read PI sheets or do their own research? We should blindly accept whatever is told to us no matter what we know to be true about what is going on in our bodies?

You want some proof that I'm not just an idiot making shit up?

http://www.ncbi.nlm.nih.gov/pubmed/12860486?dopt=Abstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17664246&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17472825&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15505173&ordinalpos=20&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Generic antibiotics? No problem. But when you start messing with psych meds or epilepsy meds, patients should be well informed what to look for.

Anonymous said...

I thought NPs work 'under' a physician. It seems to me in medicine that physician's 'diagnose' and therefore in the role of NP, if they're not acting under a physician, without proper training in evaluating drug therapy, prescriptive authority should be a collaborative sport with pharmacists.

Also, with the CEO of Drug Topics being a nurse, I don't see the credibility of any pharmacy-info-relating anything published worth more than Ladies Home Journal. (Sorry, Jim! Your column would be the only one I'd read, if I had to pay something to subscribe). Sure, JAMA run by oncology nurses. Yea

vicky said...

You ARE my hero!!!! Thank you for saying something I wanted to say for a long time and just couldn't quite find the right words to my thoughts about NP together. Thank you!!!!

Anonymous said...

That was POETRY!

Phrustrated Pharmacist said...

Maria...

Comparing phenytoin and lamotrigine is like comparing a person who eats their own turds with a completely sane, rational person. Phenytoin is considered "extended release" only because of it's irratic absorbtion. Carbamazepine induces its own elimination over time. Valproic acid was originally a floor cleaner. Lamotrigine for prevention of "going batshit" will not induce a seizure if switched from brand to generic. Nobody said you're an idiot - just stick with the brand name.

Maria said...

The links provided weren't targeted just to show that lamotrigine levels may differ, the point is that there IS significant variability with some generic drugs. That in and of itself proves that the idea that, well, generics are not the same. Everyone reacts differently to meds that mess with the brain to begin with. For me, I had a very pronounced reaction from the first generic tablet I took. At almost 4 hours on the dot I had heart palpitations, anxiety and raised blood pressure. My insomnia and overall anxiety levels were higher. It was the same way I felt on a dose of the brand that I was unable to tolerate. I contacted my pdoc and we agreed to step down because it was apparent that I was metabolizing the generic more efficiently. I went down by 25% and all was well. It was not placebo effect, I had been hoping that the generic would work as it was cheaper than the brand. I was just getting more out of the generic, the release was different for whatever reason.

My only point is that while generics are effective, and I'm all for them, they AREN'T always exactly the same and consumers have every right to know what to look for when being switched. Different formularies that use different binders and whatnot CAN change the way any given individual will react to a med. I don't notice a difference between generic benzos at all, but with lamotrigine, I did.

Anonymous said...

Maria,
Some pharmacists might discount effects of autoinduction of self-suggested generophobia brought on by rapid untoward effects of lamotrigine. It's my impression that this phenomena is singularly as powerful on the psyche as the 'placebo' effect. When we talk about use of drugs to measure psychosomatic effects, it's hard to have people describe their anecdotal experience in the terms of whether or not the drug caused, lessened, or had not a whit of effect on their anxiety.

However, the discussion about generics usually refers to the top 100 prescribed drugs, not specifically lamotrigine whose efficacy which can measured by absence of seizure activity.

Yes, people can be sensitive to excipients such as certain dyes, fillers, etc. and there is greater 'variability' of active agent content of generic drugs, but it also usually is not significant in a person so much so that dosage administration times cannot vary by more than a few minutes, that each meal and exercise must vary less than 10 % each day, along with ambient growing conditions e.g. light control, temperature, and humidity.

Kathy said...

Your cleverness has impressed me again. LOVE IT!

Flying Penis said...

Maria:

... so you've got some hard numbers on serum lamotrigine levels and efficacy in treating this "going batshit syndrome" you're afflicted with? I am genuinely intrigued. Because, well, I was of the impression that serum lamotrigine levels (from the real stuff mind you, not the cheap dangerous generics frequently manufactured by the same companies that make the real stuff...) are fairly meaningless in the context of doing useful things... you know, like managing seizures. But like I said, I am certainly not an expert in this GBS you describe and maybe 0.05% variation in Cmax could be fatal.

Oh, and I am certainly *NOT* implying that people afflicted with GBS are prone to fixating on any minor variation in their routine to the point of it leading to the symptoms you describe (racing heart, anxiety, increased blood pressure) . No, I, being a humble student of neuropharmacology, clearly recognize those symptoms as common side effects of lamotrigine. And you said it yourself; your diazepam tastes almost just as good as the real stuff, doesn’t it? Nope, not implying that at all.

Also, can you point me to the +/- 20% thing too? My nurse practitioner said she heard it from a Coreg CR rep once, but she didn't have any more details for me.

Julia said...

You are so freaking awesome.

Katie Schwartz said...

You know what's as HORRIFIC as a bad nurse practitioner? I'll tell you because I experienced it this week, a TECHNICIAN who thinks she is a DIAGNOSTICIAN.

I had big eye drama this week. When I called to explain to my opthamologist (sp) that I woke up with a growth in my eye, he wasn't in. His technician said, "Oh, it's nothing, really." My gut told me otherwise because I'd been in the day before and diagnosed with a swollen optic nerve (I digress, big eye dramz this week).

As I was sitting in the chair waiting for the doctor, the technician came in and said, "You told the doctor the wrong thing, which is why he now thinks there's something wrong with your eye."

I WAS FURIOUS.

The doctor came in and after examining me, he said, "You have a corneal eye infection that takes precedence over the swollen optic nerve. We need to treat this immediately."

I explained with snatcharella the technican from hell said and also explained that I find it incredibly inaproppriate for a technican to be diagnosing my eyes. (HI, YOU'RE ONLY ISSUED ONE SET, GOTTA PROTECT MY LADY BALLS).

He agreed and assured me it wouldn't happen again, he also apologized. That helped, I think, maybe. I don't know. We'll see.

Oh, I am on fire over this post and what happened. Argh.

Great open letter, DM.

Kristi said...

Over 10 years ago, I had increasing pain ans swelling of my left ankle/foot after a little slip and a pop off an aerobic step. Being a Nurse myself...hey, ya know...if it's not getting better? Might get it checked out.

It was my lucky day and the only one available was the NP. She poo-poo'd me as if I were some silly little twit (yea..I was working in open heart surgery at the time. Twit that)....and refused to X-ray it. Shoved an air splint my way and off she went.

Being an OR Nurse, I just called my favorite ortho's office. 'Sure, come right over'.

Oh it was nothing. Just a complete fibular fracture. Go me!

And yes....she got 'told'.

Anonymous said...

what about all these NPs running all these new clinics the big 3 are in a rush to open everywhere they can. You can only see them for "minor issues" but who is going to diagnose what is minor or misdiagnose a bigger issue as minor. It's the blind leading the blind a nurse on a power trip checkin out a person who can't name their medications beyond the little white pill, much less relieve their medical history in a coherant manner.

Anonymous said...

There's an NP in my doctor's office who sounds eerily similar to those described above.
My Doc said she regularly misdiagnoses but my question is how do stay employed?

The Alert Reader said...

I understand that the plural of "a story" is not data....

Hahaha -- too bad Ms. Monaco can't distinguish between the two.

From a comment on thehappyhospitalist.blogspot.com: http://thehappyhospitalist.blogspot.com/2009/03/nurse-practitioners-are-dangerous-and.html

physasst said...

Beloved Parrot I thank you for your comments.

Some clarification seems to be in order here.

First, PA's and NP's have some pretty significant differences.

PA's are educated in the medical model. We take one year didactic, and one full year of clinical training, mine, albeit a while ago, was about 2400 clinical hours.

NP's are educated in the nursing model. They take courses on nursing theory (which doesn't seem to have much to do with medicine) and their clinical hour requirements can vary substantially, some only get about 600 clinical hours.

PA's are dependent practitioners, we are not MD's, have never claimed to be, and ALWAYS need to practice under a physicians supervision, which can be merely an occasional visit and chart review.

NP's, in many states, can practice with complete independence, something I disagree with, but they have a powerful lobby.

PA's are regulated by the medical board, and have to complete the same CME's as the physicians, and we have to re-take our board exams every six years.

NP's are regulated by the board of nursing, and have wide variations by state as to how many CEU's they need, and most, IIRC, do not re-take their board exams.

So, there are some differences, please don't merely lump us together. For more info:

http://physasst.blogspot.com

Anonymous said...

Having half the fucking alphabet after your name don't mean shit to me. What is wrong with the following: Geodon xsxxx mg po qhs? I have yet to find a single PA or NP who can figure this out without his/her PalmPilot. The people who know the least about drugs can prescribe, but we doctors (yes, DOCTORS) of pharmacy who know more than any of you cannot prescribe. All y'all can bite me....

Randall Sexton said...

Am J Health Syst Pharm. 2006 May 1;63(9):838-43.

CONCLUSION: Physicians and pharmacists failed to correctly identify three commonly prescribed tablets more than a third of the time. The brand-name tablet was correctly identified more often than were the prescription generic and nonprescription generic products.

Maybe everyone in health care is cognitively impaired.

Beloved Parrot said...

My Dear Drugmonkey: I have come to the conclusion that you pharmacists have created your own hells.

Let me explain -- the pharmacy folks at my nearby friendly grocery store are always pleasant to talk with, always give me my drugs within 20 minutes if they have told me it'll be 20 minutes, have told me of cost savings I didn't know about, call my doctor for refills, help me decide which OTC remedy is not only better but also cheaper, and don't mind ringing up a couple of food items when it's time to ring up the drugs.

I have now come to assume that all pharmacies are like this, and that all pharmacists are as knowledgeable and helpful as mine. If I need to stop by another pharmacy for some OTC or prescription drug emergency I expect the same level of civility and service -- and I nearly always get it, too.

So, you dear pharmacists out there -- you've set the bar so high that mere mortals assume you are the god-like creatures you appear to be. And we all know that god-like creatures are that way because they are gods, right?

The next time some sleezeball comes to your drive-through window and demands you call their doctor at three a.m. for Oxycontin refills, just remember all the miracles you perform day after day and day -- and that we all believe you can keep on performing miracles even if we are just sleezeball idiots.

No one to blame but yourselves, baby!

Jenn V said...

Hahaha. I am going to post this at work.

Well presented indeed!

PharmGamerKid said...

I thought the issue w/ brand and generic and drug with narrow therapeutic index (like warfarin and levothroid) is that you stick with the same product. If you've been using brand, you keep using brand. If you've been using generic by a certain manufacturer, you keep doing using that particular generic.

Basiorana said...

I have no problem seeing a NP for things like routine treatments or if the alternative is a male doctor for a gyn appt, but I specifically ask for a doctor if I think they actually have to diagnose something. NPs and PAs are great for getting cuts fixed and routine treatments for chronic easy problems like depression (I see a psychiatric nurse practitioner instead of a psychiatrist because I have chronic depression, and basically just need scripts for the same drug in the same does every few months), but for an initial diagnosis, I'd rather see someone who studied it for ten years than five.

And I'll go to a PA for anything except a second opinion on a serious diagnosis, since I know they have a doctor breathing down their neck anyway.

physasst said...

NP's and PA's can do a quite a bit more than that. But like physicians, it is somewhat provider dependent. I function with a high level of autonomy in a large ER. I've cardioverted people, run codes, and treated many illnesses on my own. BUT, the caveat is that I've been doing this for many years and I have earned that independence. I teach residents and precept medical students as well. So I take a little offense to your comment about PA's only being good for a few limited things.

Oh, and two of my friends are PA's that have patients continually referred to them by PHYSICIANS, cause of their reputation. One is a headache specialist who manages the most complex and persistent headaches in the country, and the other is an infectious disease specialist who may be the smartest person I have ever known...physician or otherwise.

Anonymous said...

Re: Ronald Sexton

I'm sorry I didn't bother finding the article from which you're quoting, so if I'm taking this the wrong directions, forgive me--but, I find it more important to PRESCRIBE the drug correctly and then as Pharmacists do, VERIFY the drug prescribed. Of course physically identifying is obvious for Pharmacists, who have databases for comparison (and do compare before it leaves their hands).

But-MDs and Pharmacists shouldn't be/can't be expected to look at a random a** pill and know what it is. OF COURSE a brand name is more easily identifiable..hello advertisements!! They should, however, be able to see the name of a pill and know what it does or be given a symptom and know what 'pill' should be given.

IMHO, of course.

justatech said...

Awesome, awesome!!! Love it!!! We filled a woman's pravastatin yesterday and when confronted with the 80-cent copay, she stated "I wanted the brand name." I said "you do?" and she said "I want to take what my doctor ordered." The pharmacist says "This is what your doctor ordered" and began to explain that we don't even carry brand name Pravachol, when she interrupted, "NO, it's NOT. I'm a Registered Nurse and I Know that the generic is NOT the same THING." Right, then. Oh, it is so nice to know that others have the same irritations with stupid people!

Anonymous said...

Clearly many of you missed the logic boat when you complained about the attack on Nurse Practitioners/Justified sub MD professions/proclaimed full faith in your local NP.

Drugmonkey was just pointing out her flawed logic and pointing out that SHE is a moron and it is a shame she, in particular, is a health care provider.

If you are going to proclaim Drugmokey's brilliance, d it for the right reason.

Jamie, CPhT, too lazy to register a real username.

lin said...

I'm an NP in Penna, educated at UPenn. I am grateful for the excellent pharmacology coursework and subsequent pharm reviews I took to keep my knowledge base as current as possible. There are good and bad examples of any clinician (MD,DO,NP,PA etc). I understand the pharmacologic concepts of bioequivalence, equianalgesic, protein binding as well as any competent clinician. I was very well educated (and have the student loans I chose to take to get this kind of education). I have met the best and the worst individuals you can imagine who are providing excellent or truly scary care to their patients. I for one respect pharmacists very highly and collaborate with them as much as possible. My patients appreciate this, and I know I've done the best I can for them.
There are many more safe, competent nurse practitioners, and PAs (midlevels) than incompetents. If I didn't study and work to keep up, I'd be doing everyone a disservice. Please keep in mind what goes into achieving and maintaining competence. Anyone who works in the healthcare system is well aware of many stupid mistakes made by all levels of clinicians. If in doubt about meds, always, always call your FRIENDLY pharmacist! Don't throw out the good with the bad, please.

Anonymous said...

My experience with NP'S I was married to one for over 11 years. He self medicated, stole samples, met patients outside of the office and took cash for scripts.
Always assured each one of his patients that the Drs. and Pharmacists did not know what they were talking about and he could "fix" them.
He had one drug rep sending ambien to his home for over a year.
He always had the highest numbers for writen scripts for certain meds depending on his relationship with that particular rep.
Amazing and everyone of his patients and office staff thinks he is great. My advise, avoid them.

Anonymous said...

Right on!

I can only speak from my experience so here's my 2 cents. I'm an internal medicine physician with 9 years’ post residency under my belt. I work for a fairly large multispecialty group. In my clinic alone we have 3 NP's. Now, I've seen some pretty dumb things that NP's have done. Once, when my partner was out on vacation his practice was being "managed" by "his" NP. One NP kept a guy with declining renal function (CR 5) on his ACE. I just happened to be on call one night when his labs came back and I reviewed the case. I admitted the patient stopped his ACEi and worked him up for ARF.

Another one of our NP's has serious mental health issues and had a psychotic break requiring a 6week hospitalization. I happen to know that she was seeing patients just before she was hospitalized. I had one patient tell me when he saw her a few days before her she was admitted she sat on her stool shaking her head looking at his chart. She said to this patient that his heart was very bad and not much could be done for him. This was not at all the case. The poor guy was scared to death for a couple of weeks before his appointment with me.

Our third NP is perhaps the most dangerous of the bunch. She has a HUGE chip on her shoulder and thinks everyone at the clinic including the MD's are stupid. She "steals" patients, bad mouths other providers to the patients and in general undermines the cohesiveness of the clinic.

Based on my 9 years experience I am not at all impressed with NP's.

I feel we as a medical community has opened Pandora's Box by letting non physicians practice medicine as if they were M.D.'s. It's a slippery slope to say the least.

Anonymous said...

Just tripped across your column. My, my, my- such HOSTILITY! Very enlightening. As a consumer, I will certainly view Pharmacists differently from now on... many apparently arrogant and unprofessional to say the least! Perhaps a bit of therapy would help those of you with such hatred towards NPs and PAs- but then again, you would probably second guess therapists too- as you apparently know everything. Personally, I am sick of medicine's outdated, self entitled, paternalistic view. PA, MD, NP... the CONSUMER should elect who provides their healthcare. And by-the-way, I've personally known Pharmacists and/or Physicians who've made MAJOR errors contributing to the injury/death of patients- including drug abuse, fraud, misdiagnoses, sexual abuse, incompetence, mental instability, and yes; unprofessional behavior reflected here in your column that serves to undermine care. Despite your pontificating, there is no exemption from human error.

Anonymous said...

To the last post:
i agree that patients should have the right to choose their PCP, and if you want a DC then go for it. But don't come crying the drugs made you sick when a DC or NP or PA incorrectly diagnosis you, and then writes for a medicine that is inappropiate.
You the consumer comes to the counter of a pharmacy and drops of an RX and expect McDonalds like service. How many times have I heard consumers crying "how long does it take to count 30 pills", well honestly not long, but I am having to call your Doctor (NP) and tell her you have a PCN allergy and she wrote for Amoxicillin and then explain to her something everyone who has taken Pharmacolgy understand about Beta Lactams, which she must have been sick the day they learn about medication in nursing school.
Sure MDs make mistakes, Pharmacises make mistakes, Hospitals make mistake, we are human. But lack of concentration isn't the same things as lack of knowledge. And you are damn skippy we will question therapist, we are responsible for drug therpay and if a RT want to use an Albuterol inhaler and something else, she/he will undergo the same questioning i would give any RX. And you better thank your lucky stars there is someone question why a NP or PA is writting for Cipro in a five YO or why and ACE and ARB....These nurses haven't a clue. I am still under the belief that every NP RX should have to be Co-Signed by a real MD, who has had more than one Pharmacology class, and it wasn't taken at a community college
Nurses are the backbone of medical care and I think nurses do a great job being nurses, RT do a great job being RT's but NP's well I cannot say they do a good job being MDs.
Pharmacist are good at what we do, Every Pharmacist knows a quality AB rated generic is as good as any name brand. You never change seizure medication, or levothyroxine, or Warfarin, You cannot sub generic Pyridium for brand, and things like that. And id a Consumer wants name brand we are only to happy to dispense it. But given the choice of paying 4.00 or 75.00 most people say I'll take the 4.00 one.
Oh and I do tell most of my patients to fire their therapist and buy a dog, they seem to care as much as therpaist and love you when therpay is over, plus you can get an hour for a dog biscuit

James B (Future PharmD) said...

I see a NP and she is awesome. But like someone else said, they're are good and bad NPs, PAs, and MDs. I had to go to the ER twice (both time seeing MDs with years of experience) with severe abdominal pain. Neither one did nothing more than blood work, chest x-ray and an EKG then told me they had no clue. I mentioned that my symptoms were similar to what my mom went through when she found out she had gall bladder problems. They said I was to young to have those problems (I'm 19) and refused to even do an ultrasound or CT. My NP sent me for a ultrasound and then a HIDA scan. Just as suspected, I'm having gall stones. I'm now seeing a wonderful GI thanks to my NP.

Anonymous said...

A nurse practitioner nearly ended my marriage...

How hard is it to administer a standard pap? It took forever (she couldn't "find" my uterus) and it hurt like hell, and she was condescending and abrasive through the entire drawn-out exam.

I've had one partner my whole life and we've been together twelve years- and I've never had an abnormal result. But I got an email one week later saying that I had cell changes related to HPV. When I called to ask questions, all she did was send me a judgmental comment and the link to a website. A WEBSITE. REALLY. How's that for patient counselling?

I went in for a colp, and my results were completely and entirely normal. The physician suggested that this incompetent blundering idiot failed to maintain a sterile swab. The atmospheric bacteria looked like a positive result in the lab. And apparently, most of her referrals turn out this way. That would have been good to know before my husband spent fourteen days on the couch.

Definitely off topic, but when I googled "hate, nurse practitioner" this was the only link that I felt gave them the verbal beating they deserve.

Nurse said...

I think everyone needs to stop laying the blame on nurse practitioners and PAs. There are bad and good NPs, PAs, MDs in health care. I have received great care from NPs, PAs, and MDs. Lets look at the person and not the profession.

Anonymous said...

Hi everyone,

I have read most of the comments and I have no doubts of the existing irrational thinking that permeates us at times (sometimes I am guilty of it). I am an RN mostly working in ER and ICU; my whole family is in the medical field specializing in internal medicine, cardiology, pediatrics and surgery (parents and two siblings) also my brother the surgeon is marry to a pharmacist. First I like to point out that I have come to believe that education is what you make of it. Going to a very expensive/reputable university is not going to guarantee personal reputation in the medical field or any other field for that matter, it does give you a leg up though. That is why we see nurses (RNs, NPs and PA) that are very well regarded by the medical profession; those individuals make it their business to further and/or add to their education beyond their formal training and self teach themselves through books and experience, but they are the minority, I do not believe that nursing school adequately prepare nurses, if they do that at all (but that is another conversation). I strongly believe that MD not any other health professional are the backbone of medicine. Medicine can, not ideally but certainly can function with MDs only, the same cannot be said for all the other medical professions. As a general rule when compared with physicians and other practitioners I have experience that pharmacist exhibit a lack of knowledge in some medical areas such as pathophisiology, therapy, treatment and diagnostics. Pharmacist do have the skill of preparing medications and are very knowledgeable in other areas specially related to the chemistry of medications, but the real authority in this areas is reserved for the chemistry related PHD (biochemistry, biological chemistry etc) and few MDs who later do fellowships in pharmacology, biochemistry and other more scientific/research oriented disciplines and who may also hold a PHD in other hard core science area ( the true scientist mind). Many pharmacist are employed retail and their job is very mechanical and aided by the internet databases after some years they may forget most of what they have learned in pharmacy school. From my experience pharmacist think they know more than what they actually know and I have seen physicians put them to shame time after time, I am not talking about errors in writing, but more in errors in thinking. I agree that MDs have made a huge mistake letting other take less rigorous studies and be able to practice medicine but hey, money has to be made after all we live in a capitalistic society. Every year thousand of people fail to get into medical school and usually the best second choices are dentistry, DO programs, Pharmacy.

Anonymous said...

part 2

Every year thousand of people fail to get into medical school and usually the best second choices are dentistry, DO programs, Pharmacy. Nursing usually is not one of the alternatives as they realized that none of their classes apply to nursing and they must start almost from zero unless of course like me you decide to get a BS in nursing and also complete pre-med requirements. Long story short I agree that MDs should be the only ones able to prescribe, sure you may encounter an MD who is not very competent, but is not the general rule and believe me within the medical community they are spotted, besides they are the best for the job period. When given a choice between an MD, a DO, a Podiatrist( if your problem involves the foot), a nurse practitioner, a PA, a dentist who takes further boards and able to practice medicine, etc…….DON’T BE DUMB USE YOUR COMMON SENSE AND GO FOR THE MD! (and for the DO out there before you answer think and ask yourself if you would have been able to get into an MD program you would have gone that route…. No doubt you are very talented but as a general rule you come right after the MD residencies are not the same there residencies for MDs and separate ones for Dos and besides look at the USMLE stats)
Oh and by the way, pharmacist are very frustrated professional because they don’t get to play doctor like nurse, pa, and other practitioner can….lol
Who should get to decide how medicine is run..MDs, Who should get to decide prescription rights by other professions…MD’s, not pharmacists.

There is an exemption that you should be in the lookout. There are many foreign graduate physicians that become PA , NPs and RN. Sometimes they are a breed of their own and depending on their background they are sometimes hidden talents.

Anonymous said...

The defensive nurse practitioners in the forum are morons. These "studies" they claim support their competence were ALL conducted by nursing groups with major inherent study design flaws. It's the equivalent of a drug company publishing a study supporting their own drug. Wake up and realize that the education of nurses is far inferior to that of physicians. If they want to practice real medicine, maybe they should 1) go to medical school and 2) complete a residency.

Anonymous said...

Psych NP's the freaking scariest bunch of people I have ever run across........

Anonymous said...

I've read the comments here and I'm so glad to see that I'm not the only one that thinks the NP's are incompetent and don't know what they're doing. I've been seeing an NP that is a really nasty Bitch! She does nothing for medical problems and calls patients liars and incompetent. I always knew she was the incompetent one. She calls herself Dr J.. I saw a different, Male NP that has always been very professional and never claimed to be anything he isn't. He took care of 3 bad medical problems I've been having in 1 day and the other one never did a thing for me except tell me that I'm incompetent and can't live alone. So I'm really thinking that the Male NP that I saw not long ago is 1 in 10,000 or maybe 1 in 100,000.