Will More Nursing And Optometrists Lead To Erosion of Patient-Centered Medicine?

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New titles like “clinician,” “advanced practitioner” or “provider” are masking a stark reality. People will be able to practice medicine without ever attending medical school, performing rigorous residencies or be comprehensively and extensively trained as physicians. It's a frightening – and very real – trend.

We have entered dangerous times in my beloved medical profession. Non-doctor health professionals, backed by powerful lobbies, are increasingly interested in the easing of certain practice restrictions. New titles like “clinician” or “advanced practitioner” or “provider” are masking a stark reality - people will be able to practice medicine without ever having to attend medical school, perform rigorous residencies or be comprehensively and extensively trained as physicians.

This is not to diminish the powerful benefits of nurses. Far from it. But nurses are not doctors and the people most likely to get medical treatment from people who are not doctors are among the poorest that health care reform was supposed to improve. We shouldn't cave into it. From an ethics perspective alone, healthcare delivery motivated purely by greed and cost-cutting measures will not serve patients. We can't turn health care into a scenario where when money talks, ethics walk.

Here, are just a few examples that should set off alarms.. 

The Nurse Practitioner (NP) Association of New York State is preparing “to urge passage of important patient-centered legislation” but it is anything but patient-centered. Senate Bill  S.1869 ("The Advanced Directives and Defibrillator Bill") sounds nice enough, defibrillators save lives and it would be great to have them in more places, but in actuality Public Health Law would be amended to add “attending nurse practitioner” to the list of health care providers with whom patients and families can consult as they contemplate end of life decisions.

The 23-page legislation actually proposes that the nurse practitioner “may act as the attending physician” to execute orders not to resuscitate. The Nurse Practitioner lobby is framing this as a bill that finally "permits" patients to discuss their end of life issues with nurse practitioners but patients can already discuss those issues with whomever they please. The hidden problem is that nurses will have independence from physicians so that they might ultimately be “doctors” and not require consultation with them to write and execute an order not to resuscitate.

This is just the latest in efforts to make the public think they are getting care from a physician. We already have rules claiming that patients in rural areas would be better served if doctors are not needed to write prescriptions or engage in medical practice. The State of Maine (bold mine) is considering Bill LD 538 (HP 382) which is an “Act To Allow Advanced Practice Registered Nurses Who Have Attained Certain Degrees To Use the Title of Doctor.” Confusing patients as to who is treating violates all basic and fundamental tenets of the caregiving professions. 

In my article The Worst 'Healthcare': 'Stem Cell' Clinics Wrought With Red Flags, Insincerity And Blindness, I discuss three patients resultant blindness or near blindness as a disastrous consequence of having “stem cells” injected into their eyes. In it, I referenced that the attorney for one of the patients filed a public complaint that “the injections were performed by a nurse practitioner who was introduced as a physician.” In To Survive The Hospital, Make Sure Your Heart Stops On A Weekday, I discuss the tangible adverse outcomes that occur with in-hospital cardiac arrest when they take place in the evening or weekend. The skeleton crew of less experienced providers results in a lower survival rate of patients. Being seasoned and highly trained matters in patient outcomes. These consequences were echoed in Unhealthiest Reality Of Obamacare: Lack Of Doctor Choice

End of life issues are challenging, emotional and wrought with complexity. The true intent of this NY Bill is to bypass the need for NPs to consult with a physician —if an NP can “act as if”— and this will never be in the best interest of a patient.

Again, this is not to slight nurses. NPs, physician assistants, nurses and doctors alike are invaluable to the caregiving team but they all have distinct roles. When practicing within the scope of their respective training, the patient wins. What is at stake with this relentless erosion and blurring of lines is making sure patients get the best care. 

The trend is frightening and real. Optometrists are not Ophthalmologists. The former obtains an O.D. (Doctor of Optometry), goes to optometry school and learns how to refract the eye and fit for glasses. They do a wonderful job within the realm of those parameters but they do not do a residency, learn the depth of detail or patient management necessities of all disease states or pharmacology like an ophthalmologist who went to medical school and did many years of post-graduate training along with surgical sub specialization.

Yet optometrists are lobbying to expand the nature of their practice as well. In Alaska, House Bill No. 103, requests that among their abilities should include “prescription and use of pharmaceutical agents for the treatment of eye disease” and “describing the scope of practice for a licensee to perform ophthalmic surgery and noninvasive procedures.” This legislation lifts surgical restrictions that already exist and would permit optometrists to inject into the globe of the eye as well as extend their prescribing to include higher scheduled narcotics. 

With the current opioid epidemic, do we need to add more prescribers into the mix whose credentials are less extensive? 

Complicit in this trend are hospital administrations that are taxing such employees to the “top of their ticket” as one CEO of a major healthcare system publicly proclaimed in an effort to cut costs - that means getting more value from employees who can work cheaper. Doing more with less in terms of making complicated diagnoses and performing elaborate surgical interventions will never be in the patient’s best interest and negatively effects outcomes for which much evidence already exists. The coordinated effort to diminish the term “doctor” is not aligned with patient well-being and patient-centered care, as wonderfully described in this JAMA article: Eliminating the Term Primary Care “Provider."

In a letter on behalf of the American Academy of Ophthalmology and Alaska Eye Physicians and Surgeons, the authors clearly affirm “there is now data that proves optometrists who are performing laser surgery are causing harm to patients in Oklahoma.” Those battling to “Protect Alaskan’s Eye Safety” further proclaim on their Facebook page “Optometrists, who are not medical doctors or surgeons, want the Board of Optometry to have the latitude to define their scope of practice by passing HB103/SB 36. That’s like the fox guarding the henhouse. It's simple: Optometrists are NOT medical doctors NOR trained surgeons.”

In the end, the basic questions patients need to ask are:

Why would a person want to perform tasks well beyond their level of training when the risks are human life or severe, irreparable impairment?

When considering your personal decision of whether or not you want to be resuscitated at the end of your life, do you want to make the most informed choice based on the most seasoned and comprehensively trained specialist or someone who never did a residency and was not exposed to the most critically vital depths of comprehension and understanding of the future ramifications of your illness?

Finally, when it comes to surgery on your eyes, would you want someone holding the scalpel who has not seen or done it all while sleep-deprived under the most intense conditions? 

Note:

The deluge of misguided dilution of medical personnel is far-reaching. Review my article 10 Ways to Save Your Life or the Life of a Loved One to empower yourself to be your own advocate in this changing landscape that does not best protect patients.