• Rebekah Bernard

The impact of NP training on bedside nurses

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Watch the YouTube VIDEO here. Follow Natalie Newman, MD at: Get the book Patients at Risk!


Rebekah Bernard MD 0:06

Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm Dr. Rebekah Bernard, and I'm joined by my co host and the co author of our book patients at risk the rise of the nurse practitioner and physician assistant in healthcare. Dr. Niran Al-Agba.

Niran Al-Agba MD 0:24

Good evening.

Rebekah Bernard MD 0:25

We often hear it said that nurse practitioners and physician assistants need to be able to practice independently to make up for a supposed physician shortage. However, we rarely hear about another professional shortage in this country, which is a shortage of bedside nurses. Health policy experts know that there's a shortage of registered nurses across the nation and that 11 million nurses are needed to avoid a future shortage.[i] A lack of nurses puts patients at risk, with a report by the Joint Commission on Accreditation of healthcare organizations noting that quote, 'inadequate nurse staffing has been a factor in 24% of the 1600 cases involving patient death, injury or permanent loss of function since 1997.'[ii]

It is estimated that the transition of nurses to nurse practitioners has reduced the number of practicing registered nurses by 80,000 nationwide without a clear plan to replace these positions.[iii]

While organizations like the Institute of Medicine have called for nurses to expand their education to become advanced practice nurses, little emphasis has been placed on how these bedside nurses who go on to become nurse practitioners will be replaced. The covid 19 pandemic has created a particular urgency for more nurses. In fact, so much so that Adventist healthcare recently posted a call for physicians to be trained to act as nurses.

We're joined again today by Dr. Natalie Newman, a California Emergency Medicine Physician, patient advocate and blogger to discuss the bedside nurse shortage and the unimaginable call for physicians to work as nurses. Dr. Newman, thank you for being with us.

Natalie Newman MD 2:03

Thank you for inviting me.

Rebekah Bernard MD 2:04

So I'd like to start out with Niran. Do you have this ad in front of you from Adventist health? Would you like to read that out for us?

Niran Al-Agba MD 2:11

'Colleagues: In attempting to anticipate every necessary move during this pandemic Adventist healthcare has worked relentlessly to ensure that needs were met for employees, medical staff and patients. As we continue to look towards the future, we're expanding our strategy in new and unusual ways and we need your help. We're exploring the plausibility of utilizing available physicians as nurses in the event of an overwhelming COVID-19 surge.

We see what is occurring in Los Angeles, for instance, where the overwhelming numbers of patients are so high ambulances wait more than 10 hours in hospital parking lots for entry into the hospital, one of the highest lacking resources in that scenario is nursing, please view and complete the survey below that explores physician interest in being trained as a nurse in doing the survey it obligates you in no way to fulfill that role. But we would like to gauge your level of interest. Note that this would be for substantial pay.'

Rebekah Bernard MD 3:00

So many things. Natalie, when you saw this post, what were your thoughts?

Natalie Newman MD 3:05

I was flabbergasted. Initially, I didn't believe somebody would actually put that in writing. They demonstrated to me an utter lack of respect for the differences and disciplines again, and not understanding that nursing is not an entry level job that it requires skill and training, and that anybody can't just come in and fill in. And I'm not sure what type of training they're talking about they were going to provide But whatever it is, it wasn't going to be long enough. So it would not be sufficient.

So I said with the shortage of physicians, I was unaware that we have this kind of reserve of physicians were just sitting around doing nothing are available to work as nurses. That's that's I don't know, I just think it's absurd. And I that's how I responded to what I thought it was a joke. And it just showed, again, no consideration for physicians and how thin we're being stretched, and that they have no qualms about asking us to do one more thing, in addition to the other tons of things they want us to do. And there was so many other choices, you do have LVNs, you do have a ton of NPs and a glut of NPs, actually who are RNs, and you can't tell me that their only option was to find physicians. You can't not convince me of that. So it was just them depending on physicians again.

Niran Al-Agba MD 4:26

And you know what, Natalie, I think you and I actually talked a little bit on social media about this just because we sort of had to, I think really similar perspectives, but we maybe said them a little differently. And the way I looked at it was so similar to you. It's just that I found it fascinating.

We pay nurses to be doctors, okay, so so then we now don't have enough nurses. It's one of those like, you know, when 'I Love Lucy' was eating the chocolates and she started just shoving them in her mouth. That's how I feel this moment is for me, you know, we're paying the nurses to be doctors so that we have quote 'enough' doctors.

Doctors are really frustrated by a lot of things in the system. And so they're going out to do completely other things. So becoming administrators, they're working for insurance companies, they're leaving medicine altogether. And some of us souls are still on the frontlines fighting this fight. And now they want to pay doctors to be nurses. And all of this was done legislatively. And cooperatively if that's the word, you know, by the corporations who are in control of our system. So for me, that's what I found so interesting and fascinating about it.

Rebekah Bernard MD 5:32

It's like we're living in the upside down or something.

Niran Al-Agba MD 5:37

This is opposite world, right?

Rebekah Bernard MD 5:39

Yeah. It doesn't make sense at all. And so Natalie, in your tweet, you said, You know, 'I want those of you reading this to understand the significance of this request. physicians are being asked to function as nurses after some quote, training, not NPs, who are actually RNs, and not CRNAs are actually CCRNs, critical care RNs, if I mean, RN, I mean, if you want a person to take care of COVID patients, you want a critical care nurse. I mean, that would be the perfect person. And that's what all CRNAs who are nurse anesthetist must be critical care nurses and have worked in the field before they can even go to CRNA school. And they're not asking EMTs. They're not asking paramedics, they're asking physicians to go back and be nurses and to act as nurses. And what I think is so fascinating about this, and you pointed this out is that the American Association of Nurse Anesthetists put out a white paper. And it was when hospitals were asking CRNAs, to come back and work as critical care nurses. And

The AANA basically put out a white paper that says that they recognize the expertise that CRNAs can provide during this time of crisis. However, quote, 'the AANA does not endorse the use of CRNAs in RN roles specifically'.

And then they go on to say, Well, if a CRNA does decide to, quote, 'take on RN responsibilities,' which is kind of what they are trained to do, and that what they've all done, then quote, 'they may practice as an RN, if the role is within their comfort level, and within the scope of Rn practice in that given facility and state,' and etc. And then they say, by the way, though, 'a CRNA may be held to a higher standard of care and practice than an RN, consistent with the scope of practice for CRNAs in a given state. CRNAs cannot separate themselves from their advanced practice background and their highest level of education and training.'

Natalie Newman MD 7:39

But we can?

Rebekah Bernard MD 7:40


Niran Al-Agba MD 7:44

No, no, we really shouldn't be, to be honest with you this is this is a moment where I think we really make it clear that there's a nursing standard, and a physician standard. And if I choose as a physician to be willing to go back and fill a nursing role, one of the questions on the survey was, are you willing to take orders from the Charge nurse, you bet, I'm willing to take orders from the charge nurse, because if I'm functioning as a nurse, I need help in that role. And so I should absolutely not be held to a different standard than a nurse. And that is what I found. So interesting, this legal standing of I know, I am not going to step outside of that scope, if that's what I'm being paid to do.

Natalie Newman MD 8:22

And that's how most doctors responded is- that's like not in my scope. It was instantaneous, because we feel uncomfortable stepping into lanes that are not our lane. And the fact that others feel totally comfortable stepping in the hours is unbelievable.

Rebekah Bernard MD 8:39

But it's really ingrained into us through our training, we're very much taught to know what our limitation is we're taught to know where our areas of strengths are, and when we need to get help. And that's -

Niran Al-Agba MD 8:51

We're properly trained in what we don't know. We all have gaps, right?

Rebekah Bernard MD 8:56

It's about the accountability and responsibility. So for me, I anticipate, okay, I'm working as a nurse and the charge nurse asked me to do something and I know that there's a different or better way, and then I but I have to say okay, and do it the way the charge nurse says what an incredible conflict in your mind and your psyche. If you were acting in that role, I just don't see how that would work.

Natalie Newman MD 9:19

We have a [physician] shortage that's so great that they feel they need nurse practitioners to fill the gap. But there are enough physicians to function as nurses. That's it. I mean, does no one see the ridiculousness of that?

It's just like they're not even when I read it. I was like, What is happening? I feel like I'm, I feel like I'm in space somewhere like I'm in another world or something. It's, it's ridiculous. And I was offended as well because of the expectation because really, it's taking advantage of the fact of altruistic nature of physicians who want to help. And in doing that, no one asked about the legalities of it, okay. The fact that we want to help That's great. That's wonderful if doctor wants to do that more power to them, but then take into account if you're going to function as a nurse, are you protected in that role legally, because you're a physician? And did the medical board, expand your scope of practice to allow you to practice a nurse practitioner? Does your malpractice in that facility, or whoever covers your malpractice cover you for that and if not, who will be covering you if there's a bad outcome because of something you did as a nursing duty, and if you're a physician who's taking care of a patient in a nursing role, and a physician wrote the orders, which physician is ultimately responsible when there's a bad outcome, the physician who acted as a nurse, or the physician who wrote the orders and was ultimately responsible, who because you're both physicians.

Niran Al-Agba MD 10:42

This is where the captain of the ship comes in. And that's what was really interesting to watch play out is, as a nurse, if I'm serving as a nurse, I'm not the captain of the ship, I am someone on the deck. And that would be so interesting precedent wise, legally, looking at how that would play out

Natalie Newman MD 11:00

Because that's your presumption. That's your that's your presumption is correct. But an attorney may say No, you're right. And so we're right at question. No one, it was just like, we need to if you're willing to do and I'm like, Did anybody in the hospital like the legal department, ask the doctor or ask somebody? How is the doctor going to be protected? No one ever asked about us, no one ever makes sure that we're protected or safe. They just expect us to do it. And then if the crap hits the fan, then it's like, oh, we're sorry, we didn't know. And we're left to deal with the fallout. So I was angry. Because I said, again,

I'm a physician advocate, a strong physician advocate, and I'm tired of them being used as scapegoats. I'm tired of docs being rolled over. I'm tired of the toxicity directed towards them and the vitriol and then you reach out a hand and you ask them for help.

And we always, almost always say yes, but but in this case, I said, first of all, there's not a glut of us where you have enough who can just function as nurses. That's number one. And number two, it's offensive to me to nurses that you think a doctor can just step in and take over a nurses role when we're not trained as nurses and acquire specific training. And, and I think that they had a much better options that they didn't want to look at. And matter of fact, if you have a chief nursing officer, she's a friggin' nurse, tell her to contact the nursing, nursing institutions, or nursing associations and say, Hey, where can we get some extra nurses? Why are you asking physicians to step in, when you have a chief nursing officer?

Niran Al-Agba MD 12:26

Well, there is one more piece of this that I haven't seen many people talk about. And that is the last sentence of that statement where they talk about, they would be asking doctors to work as nurses for substantial pay. So for me

...looking from an economic perspective, I think it would be really interesting if suddenly, nurses can make more working as doctors, right. And if doctors can make more working as nurses than they can make as doctors, we go farther into the twilight zone in that if you can pay a doctor three times what they would make in their regular job, you have now upended our entire health care system if this becomes a trend.

Natalie Newman MD 12:59

What we have, because you guys know, I'm an ER physician, of course, and I belong to some of the ER forums. And in some of those forums, people post their job because you get some stuff on recruiters all the time. And there was jobs in Texas in a very rural areas, very, very rural, isolated areas where they needed help offering us $45 an hour, and that was not a typo.

Niran Al-Agba MD 13:20

But that is what's happening. And that's what I really find interesting about this whole notion is that doctors are now I mean, I my grandfather was a family physician, he did surgery, he did t days back then he was a GP. And I know roughly what he made. And it's about the same that I make now. He started and graduated in 19, mid 1930s. So here we are almost 90 years later, and I make the same income that he did. He supported eight children on that income, I obviously have only four. But the point being physician salary has fallen. And if it has fallen to the extent that now we can make more working as a nurse, right me That is what was really behind my fascination with this announcement. Because what is going to happen to healthcare to become a doctor and you get paid more to work as a nurse and that's fine. I'm not offended, I'm not upset. I just think you're going to pull more physicians away from what they're already doing.

Rebekah Bernard MD 14:16

Well, I mean, at least they're offering to pay doctors in this case because I have another example. That is also equally egregious, which is an organization in Austin, Texas, in which the hospital emergency department staff was let go, I don't know if they lost the contract or they got bought by private equity. But they replaced a large number of their emergency room physicians with nurse practitioners. And then not much later, they posted requesting doctors to come in and volunteer. So this is an organization that fired ER doctors and now they're posting and here I have a screenshot that says 'I am writing to request your help. Patient volumes both both COVID and non COVID are at an all time high at most of our facilities. If you our internal medicine, Family Medicine, critical care emergency room or pulmonary trained and want to help, message me. Volumes are increasing, and we need more physicians.' So it's outrageous. So Emily Porter, MD, she's a physician that is on Twitter, very active. She's the sister of a politician Katie Porter. And so she posts a lot of this kind of information. And she posted and said that doctors should really wake up to this and be aware that this is happening. And she wrote...

'Corporate Medical Group buys out local emergency physician staffing company at major hospital, including med school,' the CMG [Corporate Medical Group], 'then fires nine emergency physicians to save a buck during the pandemic, now CMG begging local physicians to volunteer including supervising non physician replacements.'

So it's just unbelievable the hubris that we're seeing from these organizations.

Natalie Newman MD 16:01

It's, um, there's this mentality that physicians are wealthy, and that we have this stash of money where we can work indefinitely for no income, I can't eat air, I can't pay my bills with I don't know, toothpaste, like I mean, I need cash. And so in addition to ask us to put our lives on the line, and then to offer someone $45 an hour, typically, that's corporate medicine, right? It's the whole purpose of it is to minimize our role and diminish our importance, and they keep doing it and keep insulting us. And then when we say no, they have the audacity to say how arrogant and that's when I wrote when I wrote a response about the number of doctors who were criticizing the docs, who were saying no, and they say, well, you act like it's beneath you. And I said, it's not beneath me. I'm not a nurse. Now, I actually do a lot of nursing things because I was taught by a nurse and I still do them to this day, I put in IVs, I've done coude Foley's I put in Foley's in G tubes, I can hang a drip, I can mix meds, I can still do all of that, I had to do it. But that doesn't make me a nurse. And they do a lot more than that. And their way in their approach is different than a physician. And we have to respect that, you know,

You cannot run an institution without RNs to run in it. If you take RNs out, it will come to a screeching halt - the entire healthcare system.

You can do without NPs, you can do without PAs. There are some hospitals I've worked in - ERs where I was outside the ER and staying in like a condo, and I was two minutes away. And the nurses were in the ER and they were like very rural area, very rural, maybe three doctors on the island. And the nurses will call me in when they knew something was coming. And these were excellent ER nurses. Excellent. So they didn't try to play doctor, but they knew what they were seeing. And I knew how to assess. And they knew when to call me in advance because they anticipated a problem and I trusted them 100% Okay, so they did it without me there. But if they weren't there, that hospital would not function. And so I have a very high level of esteem and respect for our ends. I just think that they are not appreciated. And they're not paid enough. And I think it was a mistake for the AANP and the AANA and all of those to push NPs, because they minimize the importance of nurses. And you guys know in my in my blogs, I've written a lot about the fact that when are we going to address the nursing shortage, which is much worse than the physician shortage? Why do we keep ignoring a why aren't we talking about an COVID hit, and we saw the value in for the AANA to state that they don't endorse them working as RNs. I think it's despicable and shameful in the fact that they put it in writing, because they're okay with it. Right?

Niran Al-Agba MD 18:47

Amen to everything you just said,

Rebekah Bernard MD 18:50

Both my mom and dad were registered nurses. So I grew up with them as my mentors. And in fact, they both told me, 'whatever you do, don't be a nurse,' you know, be a doctor, because then you don't have to deal with all of these aspects of healthcare. But of course, I think like many people, that nurses that become nurse practitioners, they soon learn what physicians have learned, which is that is not necessarily any better. They're just going from one role to another still brings its own problems. And the system has a way of abusing all of us, whatever role we're playing, whether we're working as a bedside nurse or nurse practitioner or a physician.

And to me, that's really what's the most unfortunate about this whole scenario, that we've entered this corporate healthcare system, in which we're all just pawns in this game, and we're all being moved around the field and none of us are being treated very well.

I think a lot of nurses that go on to be nurse practitioners are they're looking for a better way they want to continue to provide patient care and but they don't want to deal with a lot of the nonsense that they are faced with as nurses. But unfortunately, they don't know that it's not necessarily going to get any better. So we really need to address the nursing shortage. And the physician shortage, and not by hopefully changing them.

Natalie Newman MD 20:04

Exactly, exactly. I agree.

Rebekah Bernard MD 20:07

Well, I do have a few screenshots that I'm going to put up on our YouTube video, because when we saw this post asking for doctors to volunteer to act as nurses, somebody said, 'Hey, now they can take away that meme that they have.' So there's a meme that shows a very complicated setup of intravenous lines and machines. And it says, 'next time someone says, quote, you're just a nurse, quote, remember, no doctor could set this up.'

And of course, we always have our anesthesia colleagues saying 'I set up stuff like that all the time,' and critical care physicians, but so a lot of people said, Well, I guess now we can, you know, get some respect now that we can act as nurses. And a few other memes, because what you said is really true, Natalie, is that it's been it's become really fun for some people to demean and criticize physicians and mock and point, you know, just really try to bring us down. And it's really unfortunate, because if physicians did this to nurses, it would be completely unacceptable as it should be. And it should be unacceptable for anyone to do this to physician. So there's another meme that says, it shows a couple of nurses it says, 'during the 23 hours and 55 minutes a day, when your doctor is not in your hospital room, it's going to be your nurse who saves your life,' you know, implying that doctors are just that's all we spend is five minutes when you know that maybe we are in the room of five minutes.

But we're spending perhaps hours behind the scenes. But that's not known. A lot of times, yeah, I think that we could all try to talk about each other a little bit nicer, and it does hurt. And physician burnout is real physician suicide is real. And it doesn't help to have disparaging remarks being made about doctors. And I think that's something I'd like to see stop.

Natalie Newman MD 21:53

And that's why I don't have a lot of empathy for the non physician practitioners who take advantage of the fact that corporate America is demeaning our role, because we need support too - whenever they say 'Where is your support?' And you know, we work as a team, and blah, blah, blah, I said, Well, you know, doctors matter too. And we do work in a team we always have, and so to act as if that never existed, when it's always existed. That is not a new concept. It's not something you have to mandate, it was something that was just done, we've always worked in teams, it's just that it's a rhetoric, it's a selling point.

And that so many virtue signaling, doctors are falling into that and drinking the kool aid, and then being open to criticizing us, it irritates me when they criticize PPP without really knowing the background of how PPP even begun, and so but I do take issue with NPs who take advantage of the situation that we're in, you know, so if you know that nurse practitioners are not qualified to practice medicine without a medical license, and yet you jump into that role, because you can because it's being allowed, then you are culpable. And I am not sympathetic. And those are the ones I have the problem with who think that I'm a bully.

I'm not a bully, I'm just calling you out. I'm just saying that, 'You can't practice medicine without a medical license. It's illegal.' And I don't care that the legislature passed the law, they passed a bad law, and it needs to be revoked. And I think that that's the path we need to go down that has been untapped as a legal aspect of addressing this issue, which I believe inherently is illegal. I do.

Rebekah Bernard MD 23:33

I think you're right. And the other thing that annoys me, and I don't know what your thoughts are on this, but on social media, a lot of times you you mentioned virtue signaling, I'll see physicians that'll you know, write posts and say, 'Well, you know, I just want to say that nurse practitioners and nurses and PA have taught me everything that I know, in my in my training, and they are just the best and mine is the best. And mine is better than many physicians that I know.' And those things kind of they drive my blood pressure up, I'm sure you have that, too.

Natalie Newman MD 24:02

Yeah. And they never, they never say anything about the physicians who taught them nothing. And you know, during my era, we we acknowledge those physicians because I think that I'm a pretty good physician actually. And it was physicians who taught me to become a physician. Now, there were PAs, we didn't have NPs in the ER when I was training. So I work with PhDs in medical school and residency, and there were procedures that they assisted me with or taught me with if I was a medical student rotating, and I appreciated that, and I let him know I appreciate it that however, they did not teach me how to be a physician. A physician taught me that and so the virtue signaling Docs who say that what they're doing is to me is really demeaning, the physicians who actually taught him to be physicians.

Rebekah Bernard MD 24:47

Yeah, and you you talked a lot in one of your articles about how physicians need to realize that when they're training a nurse practitioner or physician assistant under them, that really that person is only as good Is that individual physician and what they've actually trained them. Can you talk a little bit about that?

Natalie Newman MD 25:05

Well, I think it's ego driven, honestly, because the doctors say I've trained, I'm just going to use as an example, cardiology, and they say, you know, really good on cardiology NPs. And first of all, there's no such thing as a cardiology NP, because there are no cardiology in NP curriculums or programs that exist. So it is a cardiologist they work with for so many months, who teaches them a certain portion of what he or she knows. And then they decide subjectively, that that NP is qualified in their opinion, and allows them to see a patient initially, like a consultants been sent to them by a physician. And I think that's inappropriate, because you're assuming that they understand everything you understand when which they don't, which what the doctors, in essence, done is an apprenticeship, which is not does not take the place of a standardized structured program, that is under an accredited body. The physician is not an accredited body, it's just a man or a woman with a medical degree, teaching someone what they know, to an extent. So that person is never going to be an expert. They're just going to be somebody who worked under your watch. And then they're going to take that and go to an unsupervised state and claim that they are a cardiology NP when they are not, or a dermatology NP when they are not.

And so when the doctors think that they've taught someone, that's because they don't understand the training of NPs, and what it actually is they think what they're doing, is teaching them medicine, and they're actually not they're teaching them how to mimic medicine.

Rebekah Bernard MD 26:33

Do you think that it's because they see them like a medical resident, but they don't realize that they don't have that training?

Natalie Newman MD 26:39

Yeah. But that's why I post the graphs and everything I do, so they can actually see the courses they take. Because all of us before, I didn't know, I supervised NPs for years, I didn't know they had zero medical training, I thought when they were advanced, because it says they were nurse practitioners, practitioner, I thought, Oh, they had some medical training, I presume they have some experience like a PA, PA is I knew, right, because they trained in the same model we do. And some of them take some of our medical courses. So I just presumed they were the same I in that sense that they were nurses, but they also had medical training.

I had no idea they didn't have any and that their only medical training is whatever they get at the bedside with physicians, they work with their apprenticeship. That's their medical training. Well, to me, that doesn't count. Because if that counted, we wouldn't have needed a Flexner report if that was if that was reliable, and it's not reliable. And if it wasn't reliable for people who are actually functioning as physicians, how the heck is it reliable?

What people who are nurses, it's not - it's the doctors ego thinking that they've taught them to be that good when they're not that good. And I think there's something we can do that would really make all these doctors see that they don't know as much as they think they do pimp them - we pimp PAs, we pimp residents, we pimp fellows, medical students. You know who doesn't get pimped? The NPs don't get pimped. If they get pimped, the knowledge deficit will become painfully apparent. But why don't they get pimped? Because they get upset and they go complain that we make them feel stupid. Now, if a PA went and did that they would be chewed out, right, we would all be treated well, you made me feel bad at the person that the attending would look at us and say, Okay, get out of here, right. But the NPs we don't do that - doctors are so afraid of the nursing establishment, they just don't do it because they don't want to make way so they don't tempt them. And they and then they don't see what the deficit is. If the one who was involved in Alexa Ochoa's case had been pimped, they would have seen that she didn't have the foundation to even be working in an emergency department.

Rebekah Bernard MD 28:33

You're making such good points. And I think you're right when you speak to the fear. And I think that's part of this virtue signaling that we see, especially in academic centers, it seems like NPs have become very powerful. And it's probably because they really do serve this role that medical residents used to be able to fill. But now because of our restrictions, maybe they can't as much, but they're definitely the academicians that I see. They seem terrified to say anything, again, that could be even perceived in a negative light.

Natalie Newman MD 29:04

But they'll criticize a doctor with no problem. They'll criticize a colleague with no problem. And I find that offensive. I will say that NPs in academic center tend to be of a higher standard. And they have been well trained. And so they do see the cream of the crop. So they have a bias. They think they all are like that. But we're seeing the ones that are coming from everywhere else. We're seeing the ones who are not in the academic centers, and we're seeing those products, and that's what they don't they're unaware of. They think it's just a small few. And I said well, no, you have 23 states in DC where they have unsupervised practice. So that's a lot of states. So that's a lot of NPs who are not supervised, not just a select few here and there, and they need to stop saying that, but that's them being in denial. And when I try to educate them, I get blocked. They don't want to know they don't want to hear that side. So they don't really want to protect the patients in my opinion. They just want to live - they're more interested in protecting the virtue of the NPPs than they are the patients. So what can you do with those docs? There's nothing you just have to let them learn the hard way.

Rebekah Bernard MD 30:02

You know, you make such a good point, I didn't realize you're right, though they are seeing the the best of the NPs, they're not necessarily seeing the online diploma mills. Although we recently had a case, we in our one of our recent podcasts, where we had a Yale graduate nurse practitioner, posting online questions that were just showed an unbelievable lack of understanding of basic psychiatric care for patients. So it doesn't necessarily mean even though they went to a brick and mortar school, that they have that basis or that foundation,

Natalie Newman MD 30:32

I think that Yale was an online program. And what's happening is it Yale, Johns Hopkins, Mayo, whatever, Harvard, you know, when they have the online programs, they become degree mills to in their writing on their name. And so they're just as bad if they don't guarantee rotations or anything. They're just as bad as Walden or University of Phoenix. And I don't view them any different, but those are not the NPs that are actually working in the academics. And the ones working in academic centers are the ones who were trained appropriately. So they do function at a higher level. And so the NPs we're speaking of would never last a day in an academic center, their deficits would become painfully apparent, and they just would not last. I think that's what the doctors miss out on.

Rebekah Bernard MD 31:13

And I think you're right, that's probably where the disconnect is. And then you have those of us in quote, you know, the trenches that are seeing what 95% of the reality that's out there. And people in the ivory tower, sometimes they don't understand that or because that's not their experience.

Natalie Newman MD 31:29

That's not their experience, they don't, they're not going to see the deficits at all, because they're supervising first, most of them are still supervising somewhat fairly closely. Even though they allowed him to see initial concepts and everything. That's where I think they may see some problems. Because the NPs are functioning at a higher level, they're probably more responsible about presenting the patient. And so they're not going to see what we see are the people who try to be the Mavericks without the knowledge

Rebekah Bernard MD 31:51

Any final words of wisdom or advice that you have that you'd like to give to patients to other physicians, listeners that are listening today?

Natalie Newman MD 32:01

I just say we have to keep educating people on the differences between the disciplines of nurse practitioner and physician assistants, and physicians, and that they are distinct, and that there is a hierarchy. And that there is a team and having a hierarchy and a team are not contradictory. You can have both and be cohesive, but somebody has to be the leader and is going to be the one with the most expertise in medicine. And that would be the ones who are licensed and trained to practice it - and that is the physician.

An educated patient is an empowered patient. So we just need to educate the patient so they can protect themselves.

Rebekah Bernard MD 32:36

Well, I'm just so glad that you're out there taking care of patients and speaking out and being a patient advocate and a physician advocate. And I want to thank you so much for everything that you do. I want to encourage our listeners to check out Natalie's blog, she blogs at authentic You can also catch up with her on Twitter, we'll post her Twitter name on podcast notes, so if you'd like to follow her, I highly recommend it. She's always very insightful and has so much so many interesting things to say. So she's amazing. So thank you so much, Natalie, for all of our listeners. If you'd like to learn more about this topic, we encourage you to get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's and Barnes and We also encourage you if you're a physician, please join us physicians for patient And of course, subscribe wherever you listen to podcast and to our YouTube channel. Thank you so much and we'll see you next time.

[i]Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing Shortage. [Updated 2020 Mar 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: [ii]Ibid. [iii] Auerbach DI, Buerhaus PI, Staiger DO. Implications of The Rapid Growth of The Nurse Practitioner Workforce in the US. Health Aff (Millwood). 2020;39(2):273‐279. doi:10.1377/hlthaff.2019.00686

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