Is PPP a 'fringe' group? Responding to the AANP's accusations in Medical Economics
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On September 29, 2021, the journal Medical Economics published an interview with Dr. Alyson Maloy entitled “Covid exacerbates physician shortage.” In the article, Dr. Maloy discussed the effects of covid19 including a push to increase practice authority for nurse practitioners. A week later, Medical Economics posted a rebuttal written by April Kapu, the president of the AANP, called “Full practice authority for nurse practitioners needed to address physician shortage,” arguing that NPs were ready and willing to fill the physician gap. Because the article included many mistruths, Dr Maloy and her colleague Dr Phil Shaffer, board members of Physicians for Patient Protection (PPP) wrote a rebuttal to the rebuttal, pointing out all the flaws in Kapu’s argument. In part 1, we discuss Kapu's accusations that PPP is a 'fringe' organization out to destroy team-based care, and explain why she and the AANP are dead wrong.
Get the book, now available on Audible! https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/ Article links: Original article - https://www.medicaleconomics.com/view/covid-exacerbates-physician-shortage AANP rebuttal - https://www.medicaleconomics.com/view/response-full-practice-authority-for-nurse-practitioners-needed-to-address-shortage PPP response - https://www.medicaleconomics.com/view/rebuttal-congress-not-the-aanp-can-resolve-the-physician-shortage
Rebekah Bernard MD 0:07
Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host and the co-author of the book 'Patients at risk: The rise of the nurse practitioner and physician assistant in health care," Dr. Rebekah Bernard.
On September 29 2021, the journal Medical Economics published an interview with Dr. Alyson Maloy, entitled 'COVID exacerbates physician shortage.' In the article Dr. Maloy discusses the effects of COVID-19 including a push to increase practice authority for nurse practitioners. A week later Medical Economics posted a rebuttal written by April Kapu, the president of the American Association of Nurse Practitioners (AANP), and that was called 'full practice authority for nurse practitioners needed to address physician shortage' and it argued that nurse practitioners were ready and willing to fill the physician gap. Because the article included so many mistruths Dr. Maloy and her colleague Dr. Phil Shaffer, a retired radiologist and research analyst wrote a rebuttal to the rebuttal pointing out all the flaws in Kapu's argument. So today I am thrilled to be joined by Dr. Alyson Maloy. She is a board-certified neurologist and psychiatrist in Maine. And Dr. Phil Shaffer to discuss this controversy. And by the way, both of them are board members of Physicians for Patient Protection (PPP). Dr. Maloy and Dr. Shaffer, welcome to the show.
Alyson Maloy MD 1:35
Thank you, Dr. Bernard.
Rebekah Bernard MD 1:37
Let's start with Alyson. You wrote the original article, and it was sort of like an interview with you, and it was called 'COVID exacerbates physician shortage.' So tell us about some of the major points in the article.
Alyson Maloy MD 1:49
The article was really looking at the impact of the pandemic on physician burnout. And part of the problem with physician burnout in the pandemic has to do with the overwhelming demands on physicians, as well as expanding the scope of practice in multiple states to accommodate the pandemic. One thing that we discussed was that, although there's been a lot of projections about shortages for physicians, that really we all have experience physician shortages here, and it's quite severe. I'm in Portland, Maine, and I practice in neuropsychiatry. And there are literally no psychiatrists accepting patients in the state of Maine right now.
Rebekah Bernard MD 2:35
You point out in the article that there's a predicted shortage of 124,000 physicians by the year 2034. And that would include primary care and specialty. And then they talked about burnout. And one of the things they asked you was, 'do you see health care organizations using the shortage as an excuse to install nonphysician practitioners in roles that a doctor should be leading?' And you talked about this legislation and Maine that was passed in March of last year. Can you talk about that?
Alyson Maloy MD 3:06
Yeah, in March of 2020, the same week that the state shut down for an emergency for the pandemic, and all medical personnel were converting our practices to telemedicine so we could continue to take care of patients safely, physician assistants were able to get a bill that had been languishing in committee for two years, pushed through in five days. And this bill basically allows them after about two years of practicing with some, let's call it supervision, can basically function as a physician, we know that they can't actually in practice function as a physician because they haven't been to medical school. But that's what's legal now in the state. And there was no end date on that legislation. So I mean, you guys both remember how much everybody was freaking out. in March of 2020. We didn't know what would happen.
Rebekah Bernard MD 4:08
Really what it was, it looks like is opportunism by physician assistant leadership to push through a bill through committee when doctors were so busy and distracted with trying to take care of patients and dealing with this emergency that they really weren't able to even respond to it. In fact, you pointed out in this article that the American Psychiatric Association, one of their experts in legislative affairs didn't even know it was going on because it was pushed through so quickly.
Alyson Maloy MD 4:35
Yeah. You know, I found out about this legislation, and I'm very interested in these topics. And I found out about this legislation when the rulemaking process was taking place with the Board of Medicine in Maine, and it was just very disturbing.
Rebekah Bernard MD 4:51
The final thing that they talked about with you is, they asked you what could be done to combat the physician shortage and you said number one, we need more physician residency positions, because we know that that is the bottleneck for getting more doctors in practice. But the other thing that you said that I really liked was you mentioned that doctors are spending so much time doing nonsense, that it's burning them out. They don't want to do it anymore. And I loved what you said, you wrote that, you know, a lot of times the non physician practitioners say that they want to function at the top of their license. And you said, 'Well, I say, let physicians work to the top of our license. We don't need to be spending 20 hours a week hitting buttons on a computer to enter information into archaic electronic health systems. It's a waste of our talent. And that would free up a lot of physician hours to take care of patients.' And I really love that because they're always talking about this idea of at the top of your license at the top of your skill set. It seems like doctors are the only ones that are actually working at the lower level, like doing data entry.
Alyson Maloy MD 5:53
Absolutely. One thing that really bothers me about all these conversations about working at the top of your license to become a physician, the three of us sitting here, we have all worked in our medical training as phlebotomist, transport, EKG techs, you know, really when something needs to be done, and everyone else has gone home, the physician stays and does it, there's no arrogance about that's not my job or this, you know, that I'm belittled by that. And so all of this work into the top of our license or non physician practitioners, there's really a push back to just wanting to work as a team to get the job done and being willing to do whatever it takes to accomplish the tasks.
Rebekah Bernard MD 6:38
You say that so eloquently. So Phil, let's shift over to the response to this. And it was really interesting, because it was only like just a few days later, I think it wasn't even a week before medical economics publishes a rebuttal by April Kapu, DNP APRN. And it was titled 'response: full practice authority for nurse practitioners needed to address physician shortage.' So what were your thoughts when you read this rebuttal?
Phil Shaffer MD 7:07
Honestly, the first time I got through the first paragraph and had to stop, it was just too upsetting. So I put it aside for a few days. And I forced myself to read through the rest of it. And, you know, it was difficult to read through because I was arguing with it at every point. And truthfully, I mean, the article is boilerplate of what they've been saying for years, and a lot of things that they can't support or support with bad evidence. It was fortunate in this situation, this is one of the few times we've had a chance to refute them on the same in the same arena. Normally, what happens is they will say these things and there's no nothing on the other side, no opportunity to correct the errors that they've made, and ask them to prove what they're saying.
Rebekah Bernard MD 8:07
Yeah, and that was actually a really great thing about Medical Economics, because they did let you and Alyson write a response in which you went point by point and showed what wasn't true. So we're gonna go through that. But before we do, I thought it was extremely interesting - I just want to read the opening to their rebuttal, which said that, 'it is unfortunate that to address the importance of solving our nation's primary care provider shortage, reducing burnout and ensuring care for rural patients amid the COVID 19 pandemic, the author opted to interview a representative of an advocacy group that exists on the far fringes of organized medicine.' And Phil, you had a pretty visceral response to that 'far fringes,' right?
Phil Shaffer MD 8:51
It's the first time, I've been called far fringe of anything. You know, this, this group is, I think, 12,000 physicians now, what she wrote is just typical propaganda tactic that you portray your opponents as somehow unhinged and use of language like this rather marks her article as a propaganda piece, as opposed to a sober piece of scientific analysis of the of the issues. She goes on further in the article and repeats this sort of thing.
Rebekah Bernard MD 9:24
Yeah, she says here that 'Malloy and PPP would have physicians and medical students believe that their profession and indeed patients are somehow undermined by the outstanding care nurse practitioners deliver.' Now, Alyson, do you feel like in your article that you've somehow undermined nurse practitioner care?
Alyson Maloy MD 9:44
This is as, as Phil had started off, saying, you know, this piece was filled with so many of the same lies that we hear constantly about why nurse practitioners should be allowed to practice medicine without the inconvenience of attending medical school and completing a residency and, you know, multi day exams. There is nothing about my position or Physicians for Patient Protection's position where we think poorly of nurse practitioners or that we do not want nurse practitioners to work on medical team that includes an expert. These conversations often devolve into, as Phil also just mentioned, sort of name calling, calling physicians who take our position as being arrogant. And it's just very difficult because we don't really get down to the heart of the matter, which is the evidence showing that physician led care is better.
Rebekah Bernard MD 10:50
Absolutely. And they go on in this article. Of course, this was their intro, and went on to say that 'every day NPs worked a lot alongside physicians who support full and direct access to NP delivered care. Unfortunately, PPP is an outlier organization working to divide NPs and physicians rather than unite us to better serve patients and our nation's health care system. And we as NPS=s want our physician colleagues to know the facts.' Phil, what are you think about that? You mentioned a little bit about you've never been called fringe before - do you think that PPP is an outlier organization? Or do you think that just doctors either don't know or they're afraid to speak out?
Phil Shaffer MD 11:33
Let me speak from my perspective, I came to PPP not knowing exactly what was going on in the NP world, I would see little glimmers of this in my practice and wondered what was this all about? And then once I became more informed, I was really appalled. The physicians we talked to generally are of the same feeling. I mean, a lot don't know exactly what's going on, particularly if you're not primary care. If you're not dealing with them directly. So yeah, it was shocking to me, that she calls us an outlier organization is nothing of the sort. I want to point out something, you know, PPP, has always from day one, and always said that we support NP practice for things have trained. And on the other hand, we always oppose the nurse practitioners going outside their scope and trying to do things that can't just as you know, I as a radiologist would be crazy to open an endocrinology office but NPs, they do this.
Rebekah Bernard MD 12:43
And I'll point out that technically you could - at the top of your license - you're a medical doctor with a medical license. So I mean, you'd probably get in some trouble. But I mean, theoretically, you could do it, right?
Phil Shaffer MD 12:55
And I will point out there is a group called the elite NP run by one fellow who is who is very strident entrepreneur, who has published courses that go for about four to seven hours of video courses that tell NPs that 'after this course, you will be able to open your own endocrinology office, or you will be able to open your own pain control practice.' And they go on and on about this. And about half of the videos are about how to bill how to do this, that, and the other. And so you've got, you know, about three and a half hours of how to be an endocrinologist, and you run out in open your endocrinology office. And this is I couldn't believe this when I first read it, but it exists. And these people are doing this and no physician would ever do this. And I want to point out one other thing. AANP says that we're trying to damage team based care and there's nothing of the sort. AANP of all the organizations is the one that is trying to remove the leader of the team from the team. The person who is the most educated, most qualified to lead the team is being pushed to the side so that their members can lead the team without proper education. Instead of PPP getting in the way of team based care, the AANP is actually trying to destroy it.
Alyson Maloy MD 14:23
That leads me to the I think it was 2019 AANP strategic plan, which is so disturbing on so many levels. For me, the biggest one is that most of it is about how they can improve their political stance and be the chosen healthcare provider by patients. Why on earth is this important? Wouldn't you think that what's important is advancing your education, staying up to date standardizing the training, stopping 100% online school I mean, on and on and on. But none of that is really in a strategic plan. It's just how can we gain political power? And really, that's why I love physicians for patient protection because this organization keeps at the center of this task patient safety. I mean, all of us who are involved are physicians, we are extremely busy people. Like Phil, I'm only a member of the group because when I moved to Maine and started seeing what was happening - Maine as a full practice authority state, now it's an OTP state too. I came in thinking, of course, 'NPs know what they're doing and can function in their capacity in which they're hired. Somebody is going to be vetting them.' You know, I'm just like, open minded, I think, as all physicians are and the only reason we have developed a position that this is not okay, is we see the carnage of patients being mismanaged.
Rebekah Bernard MD 15:53
Yeah, you actually talked about that. In your original article, you gave an example of a patient who had a finger lesion. Talk about that.
Alyson Maloy MD 16:00
A patient went to an NP who was serving in the capacity as a primary care provider. And all of us here are old enough to remember that the term PCP used to mean primary care physician. But now, thanks to the corporate takeover of medicine, the P stands for provider. [The patient] was diagnosed with a fungal infection, wasted six months on antifungals. And oh, lo and behold, it's a melanoma, the fastest metastasizing cancer we have. And that was a death sentence to this patient. No primary care physician, I don't care if your internal medicine family practice, and definitely no dermatologist, would be misdiagnosing a cancer as a fungal infection.
Rebekah Bernard MD 16:47
Or even if you maybe initially thought it was not cancerous at a certain point, and not six months later, or however many months, you start saying, 'Hmm, this isn't getting better, and maybe it's getting worse, maybe I need to rethink my diagnosis and investigate further make a referral,' whatever. And that's the problem that we see is this just, you know, hoping that things will just get better, I guess, magically on their own and just sitting on these situations, kind of makes me think of the Alexus Ochoa a case where the nurse practitioner spent 13 hours just trying different various things before she actually sought some consultation with a professional that really knew what they were doing.
Alyson Maloy MD 17:27
And Rebekah, you wrote a piece on this about the differential diagnosis. That that is the core of our medical training is learning how to create a differential diagnosis, I will never forget 'VITAMINS', is it vascular? Is it infectious? Is it you know, idiopathic, going through and learning all the diseases that could possibly explain this, and then you work through it in a in a systematic manner. Non physician practitioners don't learn that it takes us a decade to learn that. It really doesn't.
Rebekah Bernard MD 17:59
They say it takes about 10 years to become an expert in anything. And for physicians, that's absolutely been established. And it's like you said, because you need the time to learn all those possibilities within your differential diagnosis. And that takes a tremendous amount of reading and fund of knowledge. And it's not something you can learn in 500 hours or a year or two of online school as much as we would like to think so it's just not the case. And you talked about Dunning-Kruger, also in your piece and talk a little bit about that.
Alyson Maloy MD 18:31
The Dunning-Kruger effect is a cognitive bias articulated by several psychologists, I didn't learn about this until I got involved with PPP, because it is such a foundational issue and all of these conversations that are happening between physician assistants and nurse practitioners and physicians, we find ourselves in a situation in which we are trying to explain to legislators, to NPs and to PAs what it takes to learn the practice of medicine. And we are the only ones who actually have done it and know it. And we're trying to give this data to people who have much less training, if any training at all, for example, politicians. The Dunning-Kruger effect states that the more training you have, the more aware you are of your blind spots and the inadequacies of your education and the less education you have, the more you think you know, and that is what explains the cognitive dissonance. When you have physicians who have trained for 15 years. Let's use Phil's example, a NP who takes a Saturday course to become an endocrinologist. He tried to talk with that nurse practitioner to explain why they are not qualified to be practicing endocrinology for three hours from the perspective of someone who went to medical school, did an internal medicine residency and then did an endocrinology fellowship which I think three years or four years of medical school, that's 10 years, you know, the endocrinologist. But they just don't know the complexity of it. So they argue that they're just as good.
Rebekah Bernard MD 20:11
Yeah. And then the problem is, of course, what do they say that 'the eye does not see what the mind does not know'. So you cannot think about any other obscure causes of things. The first thing that pops into your mind, that might make sense, you just stop right there. And you say, 'Okay, I'm done. That's what it is.' And that's why we have patients with appendicitis being diagnosed with urinary tract infections when they can't walk down the hall. Because the first thing that the the nurse practitioner thought was, 'oh, maybe it's a UTI.'
Alyson Maloy MD 20:37
And that example, in your book, patients at risk, which by the way, is phenomenal, and should be required reading for every American, that girl died. That was somebody's child who was what, eight years old? Right? Very young, right? I mean, this is, you know, in the original interview with medical economics, I mean, they were talking about COVID and burnout. And one of the reasons that physicians are getting burnt out is we spend our lives training and medicine to take safe care of people. And you see a story of a child dying from being diagnosed with a UTI, when everything on the chart made no sense for UTI, and you just can't sit back and live this way work this way. You know, working in the medical profession these days is almost unsustainable and unmanageable due to the sheer chaos of scope of practice issues.
Rebekah Bernard MD 21:34
It really is a moral injury in the sense that, you know, people say, 'Well, I don't need to do that much training. And I can do the same thing as you' and you think, 'Geez, you know, why did I put myself through all this and go through all this?' Well, there is a reason and we can't get gaslighted into just being told well, none of that was worth it. It was worth it. It's because if you if you save one life, or you make the correct diagnosis, or you avoid making a mistake one time because it's something that you learned, it was worth it. Because we care about human lives. And we we want to minimize hurting anybody. That's the last thing a doctor wants to do. Of course, a nurse practitioner doesn't want to do that either. And I would say that many of them want to work closely with physicians and be supervised, they have told us this many times. But unfortunately, the AANP is really pushing for this full practice authority. And we're going to talk more about this in part two of our segment where we actually will go through point by point, the AANPs argument, and what the flaws are in that argument. So join us in part two. And of course, if you'd like to learn more about this topic, I encourage you to get the book patients at risk, the rise of the nurse practitioner and physician assistant in healthcare. It's available at Amazon and Barnes and Noble. Please like and subscribe to our podcast and our YouTube channel. And if you're a physician and you'd like to learn more about working with us to promote physician led care, then please join our group physicians for patient protection. You can find us at our website, physicians for patient protection.org come back and join us for part two
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