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Friday, January 16, 2009

doctor-nurses versus doctor-doctors-The AMA makes it clear where it stands

We already have doctors, folks who survive four years of medical school and then from three to six years in residencies and fellowships and pass a daunting battery of tests along the way.

We already have folks who complete a defined educational program in nursing and we have some nurses who then go past that level of education and take extra training to become advanced practice nurses. State laws vary in how much autonomy such folks have but the very name "mid-level " providers informs us that they are not at the same level as physicians.

So one wonders what would be the reason for existence of a new professional one that is a doctorate level nurse. Here we are talking about a clinical doctorate- not the PhD s that some nurses obtain in nursing educations. There is a so-far-fairly small- movement in the land which proposes that this new category of clinical practitioner is what the health crisis needs . The argument goes that there are not enough primary care physicians and too many nurses leave nursing for more rewarding careers and this doctor-nurse position will fill that need and we are told by the apparently self appointed spokesperson for that movement that:

A nurse practitioner with a DNP has achieved many of the competencies [of physicians]but through nursing education they will have the same skills in identifying a disease state and treating it but it is a different hybrid of care.

Apparently this doctor-nurse position will be rewarding and attractive to nurses even though the argument that primary care is becoming less and less attractive .

Dr. Mary Mundinger is the Dean of the Columbia University School of Nursing and holds a doctorate in Public Health (not the DNP degree she is proposing) and in this era of increasing awareness of real and perceived conflicts of interests, one has to notice that she is a director for United Health Group holding -as of Dec.11,2007- 32,000 shares.

The AMA has taken spoken out in opposition to this new clinical professional. In this era of increasing awareness of real and perceived conflicts of interests, one has to notice that the DNP would be competition for physicians.

So what is behind this doctor-nurse movement? Is it ,as Dr. Mundinger suggests,, the paucity of primary care docs and the purported exodus of RNs from nursing or can we see what is really going on if we follow the cynical but venerable follow-the-money rule. Here is DrRich's take from his June 17,2008 blog entry.

Having taken such careful pains to make primary care medicine so exquisitely unattractive to present and future physicians as to assure that the growing “PCP shortage” will become the next real medical crisis, the healthcare system is now grooming its solution to this manufactured crisis, namely, the doctor-nurses. These doctor-nurses will fulfill all the criteria the healthcare system desires for its practitioners of primary care medicine (no matter what healthcare reforms we may end up with). They will be “doctors” who are duly “certified” in primary care medicine by respected testing organizations, who have just enough training to diagnose and treat the average patient (i.e., the ones with high blood, low blood, fat blood and sugar), and who will cheerfully, unquestioningly (and with far better compliance than MDs - what with their traditions, attitudes, etc. - can ever hope to offer), follow whatever guidelines are handed down to them by the experts. And they will do it all for less pay and with less lip than the now-obsolete physician PCPs. These new practitioners of primary care medicine will be a perfect fit.

If you accept this analysis you can appreciated that Dr. Mundinger could have a conflict of interest as she is a board member of a organization that could profit from the care and feeding of this new breed of health care professional,namely (at least for a while) they will work cheaper.


Anonymous said...

So how long will it take for these nurse-doctors to realize there 1s not enough money in primary care to be worth the hassle and then will we see programs for nurse-doctor radiologists,and nurse-doctor dermatologists and nurse-doct Or will the nurse-doctors enhance their practice by employing nurse-doctor assistants?

Anonymous said...

You bet there's a conflict of interest!

Mary Mundinger, recently resigned dean at Columbia School of Nursing, established the DNP (doctor of nursing practice) and is the leading advocate for replacing physicians with advanced practice nurses. http://hcrenewal.blogspot.com/2006/03/to-whom-do-udidoos-owe-duty.html

There is more to the story.Mundinger is entwined with healthcare industry corporate interests. She is on the Board of Directors of UnitedHealth Group, Welch Allyn, Gentiva Health Systems (nationwide provider of home health & nursing services), and Cell Therapeutics.

Some of Mundinger’s recent industry compensation:

1. UnitedHealth Group, Inc (a director since 1997):
2008 -- $212,113
2007-- $329,647
2006 -- $486,325 -→ $1,028,085 from UnitedHealth since 2006 alone.

2. Gentiva Heatlh Services, Inc.
2008 -- $152,856
2007 -- $127,531
2006 -- $104,320

3. Cell Therapeutics, Inc:
2006 - $92,865
2005 - $49,250
data from: http://people.forbes.com/profile/mary-o-neil-mundinger/36513

Mundinger, a Director of UnitedHealth since 1997, HAS RECEIVED OVER 1 MILLION DOLLARS IN COMPENSATION FROM UNITEDHEALTH SINCE 2006 ALONE. As of December 2007, Mundinger held 32,000 shares of UnitedHealth stock.

In the Pulitzer Prize winning Public Service article, “In Internal Probes of Stock Options, Conflicts Abound,” the reporters note that Mundinger “ . . . shepherded a pioneering project to create a nurse-practitioner clinic in New York. The support of health insurers was critical to getting patients to use it, and UnitedHealth was among several insurers to sign on. In media interviews at the time, UnitedHealth officials spoke approvingly of her project.” http://www.pulitzer.org/archives/7186

There is also an issue of alleged involvement in the UnitedHealth options scandal. Fortune reports that the directors “made millions themselves from hefty options grants”, and that “directors regularly signed paperwork approving stock grants bearing an exercise date that was weeks earlier, when the share price was much lower”. The article provides the example of a "written action" signed by Spears, Mundinger and Kean and “authorizing hundreds of thousands of options for the company's top eight executives . . .” http://money.cnn.com/2007/04/24/news/companies/elkind_unitedhealth.fortune/index2.htm

How much of Mundinger’s aggressive advocacy to replace physicians with nurses is related to her duties to UnitedHealth insurance company and other healthcare corporations? Mundinger is a highly compensated director of organizations that could profit from her recommendations to replace physicians with less expensive (though NOT equivalently trained) nurses.

As healthcare reform continues, the issue of nurses replacing physicians will surface as financing is planned. Karen Ignagni, President and CEO of America's Health Insurance Plans, sits on on Mundinger’s Council for the Advancement of Comprehensive Care , the self-described “leading organization for the promulgation of doctoral level clinical nursing.”

Of additional concern is that Mundinger has not mentioned her important conflicts of interest in her academic articles and research reports. These articles have propelled the ‘nurse doctor’ movement, and have been cited widely. How much of Mundinger’s work reflects her professional and academic research and beliefs, and how much reflects her fiduciary responsibilities and financial involvement with the healthcare industry?

The public and Congress needs to know about the The Nurse "Doctor" Scandal, supported by the UnitedHealth Group and other corporate interests, and the efforts to replace physicians with nurses. There is an extreme amount of corruption here that has led to the inclusion of unsupervised nurse clinics in healthcare reform bills. Without physician oversight and supervision, this poses a risk to patients and to quality healthcare.”