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Expanding the scope of practice of advanced practice nurses will not endanger patients

One of my New Year’s resolutions for 2014 for the blog, besides looking for talented bloggers to add to our pool of awesome bloggers, was to try to look at areas of science-based medicine that we don’t often cover (or haven’t covered before), such as the delivery of health care. Fear not, I’ll certainly do enough posts on the usual topics, but I am going to make a conscious effort to diversify a bit, if only for my own personal growth. Ironically enough, in the couple of months before the end of 2013, just such an issue came up in my state. Uncharacteristically (for SBM at least) the topic I’m going to take a look at has nothing to do with the infiltration of the pseudo-medicine known as “complementary and alternative medicine” (CAM) or “integrative medicine” into academia or CAM practitioners like naturopaths or chiropractors trying to lobby state legislatures for greater scope of practice to ply their pseudo-medicine on an unsuspecting public. It does, however, have to do with expanding the scope of practice of a group of medical professionals, and, unexpectedly and disappointingly, it’s a proposal that’s had considerable resistance from various physicians’ societies in the state. I’m referring to advanced practice nurses (APRNs), often referred to as nurse practitioners (NPs).

Before I go on, it’s necessary for me to point out my conflict of interest. No, I haven’t received funding from the all-powerful American Association of Nurse Practitioners (whose influence, actually, is dwarfed by state medical societies and various physician groups). I do, however, have a very personal relationship with a nurse practitioner, namely my wife. However, I would point out that she hasn’t been an NP that long, and I routinely worked with NPs collaboratively long before the idea of becoming a nurse or even an NP was even a germ of a thought in my wife’s brain. Make of that admission what you will as you read on.

Advanced Practice Nursing

Nurse practitioners are different from physicians in that, first of all, they are nurses. However, they are nurses who have undergone advanced training such that they are qualified to manage common medical problems within their scope of practice. Another way that they are different from physicians is that their scope of practice is generally defined by the state laws that regulate their practice. A physician, once licensed in a state, can practice virtually any kind of medicine legally. It is the professional societies, not state laws, that determine the specialization of physicians. In practice, of course, I as a breast surgeon/surgical oncologist, can’t practice urology or internal medicine, for example. My hospital privileges don’t include them, nor would insurance plans reimburse me for them, nor would malpractice plans insure me to practice these specialties. The law, however, would not stop me. That is how, for example, Stanislaw Burzynski gets away with billing himself as an oncologist, even though he has never completed an oncology fellowship or even an internal medicine residency. (I still can’t figure out how he used to manage to get insurance companies to reimburse him for his services.) I would, however, rapidly run into roadblocks actually practicing.

NPs, on the other hand, go into training with a specific scope of practice. My wife, for instance, is a Pediatric NP. In addition, there are Family NPs, Adult NPs, Geriatric NPs, Women’s Health Care NPs, Neonatal NPs, Acute Care NPs, Occupational Health NPs, Certified Nurse Midwives, and Certified Registered Nurse Anesthetists. As the AANP describes it:

NP students determine their patient populations at the time of entry to an NP program. Population focus from the beginning of educational preparation allows NP education to match the knowledge and skills to the needs of patients and to concentrate the program of academic and clinical education study on the patients for whom the NP will be caring. For example, consider a primary care Pediatric NP. The entire time in didactic and clinical education is dedicated to the issues related to the development and health care needs of the pediatric client. While medical students and residents spend time learning how to manage adult clients and complete surgery rotations, a primary care pediatric nurse practitioner student’s educational time is 100 percent concentrated on the clinical area where the NP clinician will actually be practicing.

Most state laws are specific about NP scope of practice. NPs who practice outside of their scope of practice can rapidly find their licenses in jeopardy. Confusing the issue is patchwork of laws in different states regulating NP scope of practice. These range from regulating APRNs as licensed independent practitioners, as New Hampshire does, to having in essence no scope of practice beyond that of a registered nurse. Let’s compare. In New Hampshire, APRNs have the authority to perform medical evaluation/management; basically, they can diagnose and prescribe treatments within their scope of practice, and there are no requirements for physician collaboration, direction, or supervision. In Michigan:

…there is no statutory or regulatory scope of practice for an NP. According to statute and regulation, NPs have the scope of practice of a registered nurse. Physicians can, by Michigan state law, delegate their authority to perform medical acts.[7] So, because NPs in Michigan cannot perform medical acts without delegation, they cannot be considered licensed independent practitioners under The Joint Commission definition, but they would be licensed independent practitioners under the HRSA definition.

The AANP has a map of the US to show what sorts of practice APRNs have in each state, which range from full practice (like New Hampshire) to restricted practice (like Michigan) to something in between that the AANP calls “reduced practice,” like New Jersey, where I practiced for eight and a half years, in which their ability to prescribe depended on collaboration with an MD, but otherwise the NPs could practice nearly autonomously.

Now, you might ask, what does the HRSA have to do with anything? There’s still more confusion, because the federal government’s definition of an independent practitioner is different from that of many states. The US Health Resources and Services Administration (HRSA) also defines “independent contractor,” and, to confuse things still more, its definition conflicts with that of the Joint Commission:

Under The Joint Commission’s definition, in states where they are not required to be supervised or directed by physicians, NPs are licensed independent practitioners, but they are not in states where such supervision or direction is required by law. To HRSA, however, all NPs are licensed independent practitioners. The HRSA definition identifies as licensed independent practitioners NPs “or others permitted by law and the organization to provide services without direction or supervision.”

As the author of the above article drolly notes, if readers are confused, they are not alone. I don’t wish to dwell on this confusion other than to point out that it was Senate Bill 2 in Michigan that got me interested in this topic. The bill is designed to allow NPs to practice independently here (i.e. for Michigan to become like New Hampshire in that respect). More importantly and relevant to SBM, I also have to point out that the opposition to this law from medical professional societies was largely not science-based, and it was because of that opposition that the bill barely squeaked through the Senate only after being amended in ways that arguably watered it down and appears currently stalled in the House. Indeed, that is what disappointed me most of all. I don’t wish to dwell on the politics and health policy aspects of NP practice overmuch. Obviously more than just science determines law and policy needs, although it is not outside the range of SBM to point out that, with the projected shortage of primary care physicians over the next couple of decades, better utilizing providers like NPs to pick of the slack should be on the table as an option.

In which physicians protect their turf

An example of the sort of rhetoric being used against SB2 can be found on the Michigan State Medical Society website, there is a link to a pre-packaged letter to send to Representatives, as well as to a statement by the President of the MSMS Kenneth Elmassian, DO, that reads:

Every discussion in Lansing about health care and health policy should start and end with what is best for Michigan patients. The Michigan Senate today picked special interests over the health and safety of Michigan families when they voted to approve Senate Bill 2, which reduces educational requirements for those who practice medicine, risking patients’ lives and sending the signal to health care providers that medical education simply doesn’t matter.

Senate Bill 2 is bad medicine. Lawmakers in the state House should do what the Senate wouldn’t—reject this dangerous special interest legislation and instead put patients first.

On the MSMS Government Affairs YouTube channel are multiple short videos of MSMS members repeating the same dubious arguments:

The letter the MSMS is trying to get doctors to send to legislators, an effort that the Wayne County Medical Society is supporting by including a link to the form on its website (even going so far as to refer to SB2 as a “dangerous bill”), is no better, repeating the same point about fewer years of education, asking:

Consider this: if nurses were given this broad expansion of scope, what would happen if something went very wrong in the course of treatment–something that a nurse doesn’t have the education or training to handle? Are you willing to put patients in this precarious situation?

This is a transparently weak argument. To illustrate what I mean, let me ask: What happens when a physician encounters something in the course of diagnosis or treatment that goes very wrong and he doesn’t have the training to handle? He calls in other physicians who can handle it! Seriously, by this reasoning, no gastroenterologist should ever be allowed to do colonoscopies because he can’t repair a colon if he perforates one, and no cardiologist should be allowed to do angioplasties because he has to call in a heart surgeon to fix the problem with an emergency bypass if he messes up a coronary artery during a balloon angioplasty, a known risk of the procedure. The key is not being able to handle everything, as every physician specialist knows. The key is to be able to recognize when you’re in over your head and can’t handle a problem and not to be too proud or stubborn to call for help from someone who can handle it. You know who taught me that? Pretty much every surgeon I ever trained under. To quote Harry Callahan, “A man’s got to know his limitations.” This is true whether that person is a physician or an APRN, and APRN training pounds a knowledge of those limitations home.

I’m not likely to win friends among my peers by saying this, given that multiple Michigan medical societies oppose the bill, but, as a member of the MSMS myself, I do not support the stance of the MSMS, and I was particularly disturbed by the faulty reasoning and fear mongering being used to defeat this bill. Indeed, I’m actually rather embarrassed for Dr. Elmassian, who sounds more like a TV pundit or a politician running for office than a physician with that insulting bit about “special interests.” Seriously, I expect the President of my state medical society to make better arguments than that, even if I happen to disagree with his position. After all, I could equally argue that Dr. Elmassian is protecting physicians’ special interests against competition, which I rather suspect the MSMS is. Next, the whole argument about “reducing educational requirements” is disingenuous, particularly the nonsense about “sending the signal to health care providers that medical education simply doesn’t matter.” By that reasoning, I suppose the 17 states in which NPs can practice without physician supervision and the Institute of Medicine, which recommends that NPs be allowed to practice to the full extent of their training don’t care about medical education. The main reason that NPs don’t have as many educational requirements as physicians is because they specialize from the very beginning, unlike physicians, and they deal with a more limited scope of common problems. The AANP actually has a retort to this argument that I fully agree with:

Head-to-head comparison of educational models is not the appropriate measure of clinical success or patient safety. The appropriate measure is patient outcomes. Forty years of patient outcomes and clinical research demonstrates that nurse practitioners consistently provide high-quality and safe care.

This brings us to the real issue at hand that science can address and is thus inarguably part of science-based medicine and within the purview of this blog: Do NPs provide quality care? The AANP and Michigan Council of Nurse Practitioners argue that they do to the point that they should be considered independent practitioners. The MSMS and other medical societies argue that defining the scope of NPs would endanger patients. What does the evidence say? (Sorry about that link.)

The existing evidence base

Unfortunately for the MSMS, the evidence isn’t with it. In fact, I find it rather telling that none of the physicians’ groups arguing against laws expanding NP scope of practice seem able to cite any science. The reason, of course, is because they likely know that existing outcomes research looking at the effects of NPs on quality of care does not support their position. Let’s do a quick perusal of the literature, shall we? There are lots of studies; so I have to pick and choose, as well as take a look at a systematic review (non-Cochrane) and a Cochrane review.

One study, a chart review from 2008, compared the family practices in Pennsylvania and New Jersey to examine a single disease: Diabetes. Investigators audited 846 charts of patients with diabetes to compare adherence to American Diabetes Association guidelines for diabetes management between practices that employed NPs, physicians assistants (PAs), or neither. Practices with NPs performed better at providing some types of diabetes care, primarily monitoring tests, than physicians only or physicians with PAs, the latter two of which were statistically indistinguishable from each other. Whether there were confounding factors to account for the differences was not clear. These types of studies do exist in relative abundance. This is not new news, either. Copious evidence for the equivalence of care between NPs and physicians for common conditions that NPs are trained to manage exists dating back at least to the 1970s. For example, the Burlington Randomized Trial of the Nurse Practitioner was published in the New England Journal of Medicine in 1974. This study involved a large family practice in Burlington, Ontario:

…when two family physicians in Burlington, a middle-class suburban town of 85,000 just east of Hamilton, approached the Faculty of Medicine of McMaster University for possible help in introducing this innovation into their practice. For at least two years, their practice had been “saturated” — accepting no new patients or families because of inability to manage an increased case load. The physicians believed that their office nurses, with appropriate additional training, could assume a substantial portion of the responsibilities for primary care.

The NP training was as follows:

Before the study began, the nurses attended a special training program conducted by the schools of nursing and medicine at McMaster University. The emphasis of this program is on decision making and clinical judgment, rather than on procedural skills. The graduating nurse practitioners are qualified to become not physicians’ assistants, but co-practitioners, sharing the family physician’s responsibility for continuing care of patients. The nurse practitioner learns to evaluate each patient’s presenting problems, and to choose from three possible courses of action: providing specific treatment; providing reassurance alone, without specific treatment; or referring the patient to the associated family physician, to another clinician or to an appropriate service agency.

Patients were randomized either to NPs or one of the two family physicians at an allocation of 2:1 to doctors versus NPs, because at the time a case load half of that of a family physician was considered manageable for an NP. The resulting conventional group contained 1058 families (2796 members) equally divided between the two doctors, and the nurse-practitioner group comprised 540 families (1529 members), equally divided between the two nurse practitioners. Over the one year period of the trial, the number of deaths between the two groups was not statistically significantly different, nor was there a difference in physical status in terms of physical impairment, activities of daily living, or disability. The investigators noted a 5% decrease in gross practice revenue, but that was because the physicians were not billing for NP services. It was estimated that if the practice could have been reimbursed for their services, the increased volume of a 22% rise in the number of families under care could have produced a 9% increase in income.

Of course, these two studies are not examples of studies comparing physicians with NPs practicing independently. One of the earlier such studies I became aware of was a randomized study published in 2000 that randomly assigned 1,316 patients to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. (Ironically, the study was published in that mouthpiece of the American Medical Association, JAMA, and is available in full text for everyone, no pay wall.) The outcomes compared included patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. There was no difference in any of the parameters between physicians and NPs, other than that patients with hypertension were found to have a barely statistically significantly lower diastolic pressure at six months when treated by NPs and that patients rated provider attribute scores slightly higher for physicians. The study had limitations, such as being primarily a Medicaid population and thus not necessarily generalizable to an overall patient population and only following patients for a year, but overall it strongly suggested equivalent short-term outcomes.

There are multiple other studies. For instance, a randomized study from 2004 similar to this one found no differences between the groups in health status, disease-specific physiologic measures, satisfaction or use of specialist, emergency room or inpatient service. However, given that there are enough of these studies out there to result in systematic reviews, let’s check out the systematic reviews. For example, by 2005 there were enough studies for a Cochrane systematic review on the topic. Cochrane concluded:

The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.

A more recent systematic review from 2011 by Newhouse et al. examined the published literature between 1990 and 2008. Authors included randomized controlled trials or observational studies of at least two groups of providers (e.g., APRN working alone or in a team compared to other individual providers working alone or in teams without an APRN), conducted in the United States between 1990 and 2008, and reported quantitative data on patient outcomes. The review started at 1990 because practice and interventions have changed since before then, and studies in which health outcome effects could not be isolated to the involvement of NPs in patient care were also excluded. They found 69 studies (20 RCTs and 49 observational studies) that met these criteria, of which 37 were about NPs.

Among the conclusions:

  • This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included.
  • Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients.
  • The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.

Although there were limitations in this study, including heterogeneity of studies, limited number of randomized designs, often inadequate descriptions of NP versus physician roles for purposes of the studies examined, and the difficulty in attributing to the NP specific outcomes, at the very least we can say that this review of the literature does not support the contention that expanding the scope of NP practice is likely to result in decreased quality of care. Taken in its totality, the medical literature on the subject does not support the fear mongering about SB2 in which the MSMS has been engaging. It’s shameful. There might be political or economic reasons to oppose the specifics of the bill (although, if there are, I haven’t yet been convinced of any of them), but there are no scientific reasons to oppose it on the basis of patient safety and quality of care. The MSMS and the rest of the Michigan medical societies who make this argument are, quite simply, wrong. The scientific literature does not support them, and I rather suspect that they know it. If they had any outcomes data to support their fear mongering, they would have cited it. They don’t, because there isn’t any. Even the Institute of Medicine says so, and I bet any of my colleagues who oppose SB2 can’t prove me wrong.

I support increasing the scope of practice of APRNs/NPs commensurate with their education and training. Existing science and my own personal experience that began when I first started working with NPs in 1999 lead me to that conclusion. If there were strong arguments against this from a patient safety standpoint, believe me, I would have grave doubts. (After all, I am a physician, and I recognize that my inherent bias would almost certainly be that physicians provide better care, making me more inclined to take such arguments seriously if they were evidence based.) There aren’t, at least none that are scientifically supported by outcomes data, which is why the reaction of my fellow physicians to such measures, which occurs in every state where such bills are introduced, saddens me. It’s pure turf protection, nothing more. My recommendation to my state medical societies would be to spend less time trying to shut out APRNs and more time trying to prevent naturopaths from being licensed in Michigan. That would prevent far more harm to patients than the worst fears the MSMS can conjure up about expanding the scope of practice of APRNs.

Posted in: Politics and Regulation, Public Health

Leave a Comment (196) ↓

196 thoughts on “Expanding the scope of practice of advanced practice nurses will not endanger patients

  1. goodnightirene says:

    It makes a nice change to read about a science-based topic that isn’t sCAM, so I’m in favor of your resolution.

    I see NP’s all the time. Here in Wisconsin, you see the NP, who spends a lot of time taking history and (imagine!) just listening to your complaint. She (it has always been a she for me anyway) then pops out to consult with the MD, who may or may not pop in to ask a couple of questions, and then the NP returns to discuss the treatment plan with me. This is particularly helpful at the Allergy Clinic where the array of treatments for asthma can become overwhelming (use THIS inhaler THIS way and the OTHER inhaler at these times in THIS OTHER way, and so on, plus the nose drops (2 types), the use of the nebulizer and the meds that are used with it, and so on.

    It has certainly increased my ability to use these medications appropriately since working with the NP. With gynecology, it has been a similar experience, with more time to discuss options and actually practice (with a diaphragm for example–I hit my limit of comfort trying to do this with a male).

    NP’s can do a lot to prevent the hyper-sensitive from being offended at the rush of the typical physician contact, which has sent many an acquaintance of mine running to the nearest naturopath/chiro/acupuncturist. Shame on the Michigan docs for fulfilling a negative stereotype of greedy doctors.

  2. MZM says:

    An entire article written about increasing practice scope for APRNs, (written by a biased party not surprisingly), with not a single mention of PAs. More marginalizing of their equivalent counterparts, and more rebellion against professionals with superior training who are AGAINST expanding APRNs scope.

    I hope the MSMS fights this tooth and nail. You guys are way out of line and need to know your place. If you really want independent practice so bad, GO TO MEDICAL SCHOOL.

    1. David Gorski says:

      This is not a post about PAs, and, more importantly, PAs are not lobbying in my state for increased scope of practice or independent practice, nor are specious arguments being made against the quality of care provided by PAs. Finally, even PAs themselves, through their professional organizations, define their practice as being under the supervision of a physician. See:

      http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_State_Affairs/Resource_Items/PI_PhysicianPATeam_v3.pdf

    2. La Keisha Keneti says:

      I respect your opinion, but feel as though there may have been some oversight while you were reading the post. A nurse practitioner does not have to go to medical school, because they already have advanced training which has prepared them to diagnose and treat medical problems within their scope of practice. This practice is similar to a physician. Furthermore, nurse practitioners learn to follow their scope of practice from their previous role as an RN. Nurse practitioners must also have work experience as an RN to enter Nurse Practitioner school. Nurse Practitioners are not looking to take over the medical field but instead increase patients’ assess to quality health care. Physician Assistants work under the supervision of a doctor. Their education and training is performed considering that fact. NPs are educated and trained for independent practice although, they may need to collaborate or consult with other healthcare providers when deemed necessary. This is the same with medical doctors, as stated in the blog post. Nonetheless, your opinion is respected. I think the author of this post is trying to increase necessary public education and awareness.

    3. ambrozia web says:

      So we are supposed to defend PAs too? You want NPs to mention you then you slam us. If you don’t want independent practice fine, don’t go for it. NPs have had it already in many states for years. We are not and have never been controlled by MDs like PAs have. Even nurses have not been controlled by MDs since the mid 1800s…we control our own boards. We need to fight for our rights because MDs have well funded lobbies, but they do not get to make all the rules for healthcare just because they want to. The stats about our care demonstrates our safety record. Your opinion is not a statistic.

      1. T.J. says:

        OK—-Let’s take a trip down memory lane concerning PA’s. This sub specialty was created as a response to the refusal on the part of NP’s very early on to work “under” physicians ( can you spell monopoly?). PA’s are part of medicine not nursing. It has been my experience that PA’s hold roles and positions originally designed for APRN’s, they are not part of APN!

        As a professional nurse and APRN of 37 years, I possess a body of knowledge that is distinguished by nursing theory, knowledge and science. While parts of this knowledge overlap with medicine it is not the body of knowledge of my profession. I am a nurse.

        I have been shocked at the “blending” of nursing and medicine that has occurred over the years. I worry that patients will not have access to nursing care in the future as our systems increasingly make way for the medical model negating the profound contributions of nursing ( epidemiology, American Red Cross, Midwives of Kentucky, shall I go on?).

        Let’s have some healthy boundaries which are not defined by fear and special interests. First do no harm to one another. Let’s use our knowledge to serve our patients well.

  3. windriven says:

    My only questions, given the apparent high quality of care, is the differential costs of training and compensation between APRNs and physicians, and the length of time necessary to train APRNs. These factors, in my mind, are important in assessing the differential socio-economic value of increasing funding for APRN versus MD/DO training.

    There has been little appetite in either the MD community or the federal government to substantially increase the number of medical school slots (which have had some modest growth) or residencies (which have been flat since the days of Bill Clinton). Yet demand continues to grow for medical services and may be expected to accelerate under ACA.

    Increasing usage of APRNs and PAs may be a cost-effective way to address the growing disparity between supply and demand.

    I also worry though that increased utilization of APRNs and PAs will lead to an expansion of woo. I have no evidence to support my sense that medical paraprofessional training seems far more woo-friendly than physician training. I certainly hope that my sense is wrong.

    1. Beth says:

      As a student FNP, let me assure you that evidence based practice is pounded into our heads. We take classes in biostatistics, epidemiology, and use the same sources for information as our physician colleagues (I.e. Pubmed, uptodate, etcetera). We are also required to implement a project that incorporates EBP into a clinical setting before graduation.

      1. windriven says:

        @Beth

        I am relieved to hear that and I hope that is uniformly true across the various programs offering APRN training.

      2. gervasium says:

        The US is a country where Doctors of Osteopathy can be primary care physicians. I hardly think increasing the scope of practices of nurses will endanger the quality of health-care that much.

        And obviously organizations like the ones mentioned in the article are trying to defend the job of their members, much like a union.

        I am interested in understanding how all of this works, though, and I’d be happy if someone put it very simply.
        So, APNPs are nurses that do nurse stuff in specific areas, and they want to do more stuff that they argue they are already qualified for. What responsibilities and whosedoctor’s responsibilities would they take over? And what would be left to differentiate the two jobs?

        1. gervasium says:

          I meant APRN.

          1. I am a family nurse practitioner. I have 4 years of clinically based graduate education. After this I worked for many years. I estimate that I have seen over 30,000 patients prior to going to graduate school. I then went to graduate school for 3 more years where I specialized in family practice. My entire graduate education was designed around the family practice setting. Then after graduation, I took a national board certification exam in the area of family practice, so I am board certified in family practice. My credentials read as follows: MSN (which is masters of science in nursing), APRN (advanced practice registered nurse), FNP-BC (family nurse practitioner – board certified). I was trained to diagnose and treat both acute and chronic medical conditions which commonly present in the family practice setting.

            1. 4 years undergraduate, 3 years graduate…

        2. JSK says:

          Is this a poorly constructed dig at Doctors of Osteopathic Medicine? Notice how I used the proper term. We aren’t Osteopaths or Doctors of Osteopathy. If you are going to lob insults at people with professional degrees over the internet at least try to get the terminology correct.

  4. Michael says:

    I have been a Registered Nurse for 25 years now, does that show a lack of imagination?
    I am commencing my Masters this year and training as a Transitional Nurse Practitioner specialising in aged care.
    NP’s here in Autralia have also met with some resistance from Doctors who also seem to be ‘protecting thier turf’ but maybe not as vocally as the situation you describe.

    Thank you for the , as always, interesting article.

  5. EmJC says:

    Thank you for this essay, Dr. Gorski. I am a Family NP who takes care of uninsured and migrant workers and I’m a big fan of SBM. I appreciate your presentation of the pertinent research on NP patient safety and quality of care and straightforward explanation of the nature NP education. Many articles about NP scope of practice often include interviews with a representative from the AANP with some vague reference to the IOM report or other research *but* quickly turn to “the other side” who present their “grave concerns about patient safety” with no reference to evidence but lots of mealy-mouthed objections. The articles on NPs often play out like vaccine debates where science is presented first but is almost always followed by interviews with the anti-vaccine folks who appeal to “grave concerns about patient safety”.

    1. Yes. The biggest safety concern that I can identify is the blocking of access to care for underserved and at risk populations. Organizational policy which adopts a self-serving stance, that is not evidence based, does a tremendous disservice to patients who may benefit from improved access. This is perhaps the most valid safety concern.

  6. Beth says:

    It’s nice to see positive commentary on APRNs on this site. I’ve often worried that APRNs might be lumped in with other non evidence based practitioners here. It’s nice to see the support and understanding of our profession.

    1. David Gorski says:

      To be honest, I’ve seen no clear evidence that APRNs are any more prone to woo than physicians. Remember, Andrew Weil and Mehmet Oz are both MDs. So I wouldn’t be surprised if there are APRNs practicing “integrative medicine” or CAM. In fact, I’d be surprised if there weren’t. I just haven’t seen any evidence, either published or from my own anecdotal experience, that APRNs are more prone to pseudomedicine than a typical physician. I will concede that, given the unfortunate propensity among nursing programs to teach therapeutic touch and other pseudomedicine, it’s possible that APRNs might be more susceptible to the appeal of CAM. Again, there’s no evidence supporting such a tendency that I’m aware of, and, given how many medical schools are embracing CAM so enthusiastically these days, I fear that any difference in susceptibility to CAM, if it even exists, is likely to decrease as time goes on, as MDs “catch up.”

      1. Beth Henson says:

        I would never say that APRNs aren’t susceptible to the woo; just as any other medical professional is. I would say that those who fall under its spell are deviating from their education and are an embarrassment to the profession. Just as Dr. Oz is to his. Things such as therapeutic touch are taught in nursing school, but it’s meant to be used as an adjunct to medical treatment, not a replacement. It’s part of the idea of treating the whole person, as in holding a person’s hand when giving them bad news, or giving a patient a back rub when having trouble sleeping. One of my mother’s biggest complaints about a provider is often that he sat across the exam room and never touched her. Of course, that’s not something every patient wants or needs, which is another reason why there is more than enough room to go around for different types of providers and personalities.

  7. MTDoc says:

    Where to start. I am a dinosaur for sure. My generation started out as “GPs” and, after appropriate residency training, called ourselves “physicians and surgeons”. Soon we obtained specialty status as “family physicians”, but training soon changed in scope. FPs now do no real surgery or hospital care, and very little OB. In our day we were ideally suited to the small communities where we practiced without specialty backup. Our hospital had one OR, one nurse anesthetist, we provided our own instruments, and would be called in at night to restart IVs. The ICU was a bed in the hallway next to the nurses station. That all changed for the better, of course, and now we have two modern facilities within 15 miles, which include neurological and cardiovascular capabilities. In my latter years, I’ve worked with PAs and NPs, and for the most part have felt they fill the redefined role of PCP quite well. My only real problem for a physician, is why spend all those extra years in a field where you have so little to add? I made the right choice back in 1965, and I’ve had an exciting and rewarding life, but if I was starting out today it would probably be in orthopedics. I do think the “paramedics” are here to stay, and that they may actually improve most primary care.

    1. Dave says:

      I agree with you. I actually think that in the future primary care internal medicine and family practice will wither and possibly cease to exist. According to the most recent issue of Mayo Clinic Proceedings, 50% of primary care physicians are planning on cutting back or retiring completely within the next three years. There’s already a shortage and by necessity NP’s will fill the gap. Additionally, as you mention, why go into primary care as a physician? The training is longer and more intense and once you get out, if the powers that be have any say in it, you will have burdensome mandatory board recertifications every few years to maintain your licensure to do something an NP will be doing with a lot less hassle. Most internists will become hospitalists or subspecialists. A few idealistic souls may still go into Family Practice but nowhere near enough to fill the primary care needs of the country. Those that do will end up seeing the more complicated patients and probably be given less time to do it.

      NP’s and PA’s will be a necessity.

      I’ve worked with a lot of NP’s and PA’s. Some are great, some are average, as are physicians. The only thing I’ve noticed is that some of them are fond of prescribing things like vitamin C, multivits, zinc etc without obvious reason. I dont have a scientific study to show they do this more than MD’s and my numerator is obviously limited. The radiologists at my hospital say they order more x-rays, but I’ve noticed the radiologists also complain about physicians ordering studies they dont feel are indicated.

      As far as therapeutic touch, when the study was reported in JAMA many years ago about this modality, and showed that touch therapists were not capable of feeling an “energy field”, the comment was made in the article that about 50% of nursing schools at the time taught therapeutic touch. I do not know if this is still true.

  8. Michael says:

    Beth,
    Correct me if I’m wrong but it seems that you have confused Therapeutic Touch with touching someone therapeutically.
    If you are in fact referring to the woo TT I would disagree that it is a meaningful adjunct to medical interventions and phrased in this way reminds me of the term ‘complementary medicine’. It is nonsense that diminishes the profession of Nursing and is harmful to the patient not least by opening the door to other nonsense. It is harmful in the same way that homeopathy or reiki is harmful even when used as an adjunct to science based interventions.
    If however you are simply referring to physical contact with another human being during times of distress, I stand corrected. Sorry but woo in my profession pisses me off.

    1. Andrey Pavlov says:

      @micheal:

      Spot on. There is much confusion on this at all levels. I think that partly by design and partly by evolution many CAM terms are often double-meaning such as the chiropractic subluxation. Subluxations are real. And we do reduce them by manipulation. But the chiropractic subluxation is complete bull. Same with TT. I often take a moment to put my hand on a patient or family member’s shoulder in empathy and have even been known to hug a patient from time to time (despite reading an essay called “Hug a patient, call a lawyer”). But that is not what Therapeutic Touch(R) is.

      1. irenegoodnight says:

        I hug my doctor frequently–we are both heterosexual women, but I’d hug her just as much if she was a lesbian or male. Sad to hear it’s a risk factor for litigation–it’s something the alties are very good at.

        1. Andrey Pavlov says:

          Indeed. I think there are many factors why a physician may be uncomfortable with physical contact of a patient in something other than a strictly clinical manner. Certainly it is not always appropriate. And forcing it is always a bad idea because then it just “gets weird” for everyone. But a genuine hand of empathy, hug of joy or sorrow, or even just shedding some tears is, IMHO, important and very reasonable. However, you DO have to be at least a little bit aware because the interaction is inherently very different than a standard social interaction and the population with whom you are interacting is also selected and different. I think the risk of litigation is low overall, but higher than, say, hugging someone at a bar after you’ve just met and had a good conversation. Just something to be cognizant of, not afraid of. Once again, IMO.

    2. Beth Henson says:

      Michael,

      I guess I was confused. I didn’t know that there was such a thing as TT. Learn something new everyday.

      1. David Gorski says:

        Wow. I don’t know if you’re fortunate or unfortunate. :-)

        Search SBM for “therapeutic touch.” It’s basically a variant of reiki and other “energy healing,” in which the practitioner claims to be able to manipulate patients’ “energy fields.”

        1. Ceridwen says:

          I’ve often wished I could go back and unlearn about TT. I first heard of it when I was riding horses in middle and high school and even at 13 or so it was immediately obvious to me that it was ridiculous. I was particularly bothered by how much money people were spending on these things when it seems so clear that there was no way it could work.

          I think that learning about TT and other woo through horseback riding is actually what generated a lot of my interest in alternative medicine though, so perhaps it wasn’t all bad.

        2. I am a FNP and don’t know anything about this therapeutic touch. I did not learn this. I do however know about quality metrics, levels of evidence, the strength of a study, and translating evidence into clinical practice, with the intention of providing the greatest benefit to my patients.

        3. ambrozia web says:

          Didn’t know TT was taught in nursing school now. How sad. Nurses are subject to woo, like others, because of cultural influences that are difficult to break. I did notice one big difference in the daily life of RNs vs NPs when I became one 20 years ago; RNs do not read journals as often as NPs. Perhaps if this practice were instilled in school, woo would have much influence. Perhaps.

          1. Jeffrey says:

            As a nurse practitioner (ACNP), I thought I would chime in on the “therapeutic touch” being discussed. It was discussed as a possible component of nursing care in my RN program. (I’m fairly young so this would be a recent curriculum.) The way it was introduced to us was not in terms of energy fields or some actual means of altering a physiologic process. Rather, it was presented as a means of providing empathy/comfort/reassurance in the appropriate setting. (In other words, if you’re not good at reading people or body language, don’t do it!) And it is more in the sense of a hand on the shoulder.

            If anything, I would say that nursing is intentionally moving away from “woo.” There is a lot of emphasis on evidence-based practice both in terms of patient care and at systems/policy levels. In addition to tests and lectures, my ACNP program required a paper in all of our classes that analyzed evidence and its application to patient care for a certain problem. I think I had papers on pulmonary emboli, subarachnoid hemorrhage, pulmonary tuberculosis, Pneumocystis pneumonia, pharmacology of HAART in ICU patients, mechanical ventilation of patients with COPD, and the use of telemedicine in rural ICUs. (You can tell I love pulmonary critical care!) Just to add to the point made above that evidence-based practice is now drummed into your head as a nurse practitioner student!

      2. Chris says:

        Interestingly TT is the subject of a paper by one of the youngest to ever be published in JAMA: A Young Skeptic: Girl’s Science Project Shakes Medical Establishment.

        It is a good sign when you don’t know about it.

        Also, what I like about nurses working independently is that we get more time with them. My son has spent more time in hospitals than I care to think about, and the only people who are willing to explain and talk have been the nurses. The doctors (sometimes trailing a herd of interns/residents) pop in and out, but the nurses are always there.

  9. Andrey Pavlov says:

    An excellent post indeed. And an interesting one as well. I am probably biased since my entire medical experience has involved working with NPs and PAs. From my undergrad research in heart failure, to my work as a trauma tech in the ER, to my medical training in Years 3 and 4 of medical school they have always been a part of how I have seen medicine done and it has always been a very positive and fruitful experience.

    Yes, there are going to be “bad” ones who go outside their scope, who don’t know or recognize their limitations, who are too arrogant to ask for help, or whatever. But those sorts of physicians also exist. In fact, one anecdote is that during my time in the ICU the PA I worked with was honestly at LEAST as good as most of the attending physicians.

    The key, I think, is to recognize the fact that many conditions have become routine. Particularly in outpatient medicine, most of what we see is pretty rote and straightforward and there is honestly no reason to have the vastly excess amount of education and training we have in order to manage those sorts of patients. As my step-father (a critical care physician for a few decades now) likes to say, 80% of medical conditions can be diagnosed and treated by the ladies at the hair salon. We train for so long and learn so much to make sure and catch that 20% that doesn’t quite fit. The point being that there is absolutely no reason NPs (or PAs) can’t handle the majority of cases within a specific field. As Dr. Gorski pointed out, it is the foolhardy physician that overestimates his or her abilities and doesn’t call for help when needed. In fact, in my medical education it was drilled into our heads that the first step of any emergency is “call for help.” And they know they are training physicians here.

    I think an important part of it – and really the only way that patient safety could actually be endangered (well, moreso than physician care) – is to make sure that the APRNs/PAs actually have access to help should they need it. But that is true for any practitioner of course.

    Obviously, since the education is less broad in scope than our own and the training less, it is also necessary (IMHO) to specialize up front… which they already do. I mean honestly, I have zero interest in pediatrics. In fact the most common thing I heard on my pediatrics rotation was “That is absolutely correct… for an adult.” Yet I had to rotate through it, do pediatric surgery, and my board exams all have pediatrics on them (Steps 1, 2, and 3 of the USMLE – not my subsequent specialist boards). Why? So I can be more comprehensive and have flexibility in where I want to go with my career. But if I already knew I wanted to do pediatrics, why not just go directly that route? In the new era of medicine – which is, absolutely and unequivocally a team effort – it makes perfect sense to have people with less overall education and training but with just as much (if not more) in a specific field of medicine. I think medical school and physician training are great for people who want more comprehensive education and abilities or who are just unsure of where they want to go with their careers. Having an opportunity to sample all the different fields of medicine is highly valuable. But if I run into a kid on the streets in severe medical distress my first action will be to call for help, then do general stabilizing and temporizing measures, and then get that kid to someone who knows how to do medicine on children!

    There could be the argument that giving APRNs independent practice rights could jeopardize patient care. Horse hockey. That argument is like saying that the existence of urgent care centers jeopardize patient care because they aren’t full ED’s. It is the responsibility of the urgent care to refer and act rapidly as necessary and it would be the same responsibility for independently practicing NPs. Just as my license will be on the line if I don’t act in accordance with my own practice limitations, so will theirs.

    In an inpatient setting, I think it may be possible for APRNs to act independently in low acuity setting but I would be hard pressed to think it makes sense in a critical care setting (though I am very open to being convinced otherwise). That said, they make invaluable assets to critical care teams and I have thoroughly enjoyed working with them in those settings. It is amazingly wonderful to be able to kick around ideas and discuss patient care plans with someone who actually understands what you are saying. And to then be able to delegate tasks in order to make workflow go better is awesome. If I don’t have time to place a central line I know the PA/NP can do it for me and we can get more patient care done and focus on the real meat of medicine rather than the procedural stuff which just takes up time. You do not need to be a physician to place a central line. Yes, complications happen. But if I caused a pneumothorax or induced ventricular tachycardia from placing a line I would still call for help as well. There’s no room for cowboys in medicine anymore, no matter what your training and education.

    Sorry for the rambling comment. Been putting it together in between doing other tasks. Basically I wanted to lend my support as a newly minted physician for advanced practitioners (or mid-level practitioners, whatever term is better/more favored/less offensive). They will prove to be an invaluable asset in providing good quality care at all levels. The only real trick will be ensuring that their education, training, scope, etc are defined and done well… but that goes the same for physicians as well.

  10. Birdy says:

    Where I live, we have a serious issue with access to primary care. We also have amongst the oldest populations in the country, thus a high proportion of chronic disease sufferers relative to our population.

    Fortunately, the province has been bringing in NPs recently and I am beyond pleased to see it, though there are still some issues with scope being worked out, and a bit of pushback, if I recall properly. I don’t quite get why it has taken so long for them to tap into this resource. It’s a single payor system, there is no shortage of patients in need, NPs cost less, the evidence shows patients are well served by NPs. Why the resistance?

    I work for and with nurses who work (extremely well) with vulnerable populations so I may be a bit biased myself.

    How refreshing to see a topic like this posted. Thanks, Dr Gorski!

  11. A good floor nurse is worth her weight in Gold! NP and PA can do the bulk of the general medicine just like any resident or new anointed physician. They grow into their roles just as physicians. The more NPs and PAs the more we can cut the overall cost of healthcare.

    A big plus is that these providers actually use their eyes, ears and hands more often than physicians who go directly to the high technology. This can also save a lot in unnecessary diagnostic and radiological ordering.

    In the 80s, I projected that these guys would be ubiquitous especially by 2014. I was wrong, due to this slow moving Titanic and the turf battles for job security.

  12. GC says:

    Dr. Gorski:
    Would you be in favor of training SNPs, or Surgical Nurse Practitioners? Anyone who has been around surgery knows how simple and straight forward it is to do many surgeries. First assist nurses and PA’s already do a large portion of many surgeries so why not train them to do the whole thing. The can always consult a MD Surgeon when the SNP needs assistance. Thoughts?

    1. Andrey Pavlov says:

      I would be interested on your thoughts as well. I’ve been first assist many times and primary surgeon a couple of times, but I certainly would not be comfortable doing the whole thing of ANY surgery unless I REALLY had to. My thought is that in surgery there can be numerous unforeseen circumstances that need immediate correction/management otherwise patient welfare really is at stake. Surgical residencies are 5 years long and now that there are limitations on duty hours many 5th year residents are saying that they feel underprepared to practice on their own.

    2. David Gorski says:

      I would note that NPs and PAs already do a fair number of surgical procedures, unsupervised, such as putting in central lines, floating Swann-Ganz catheters, inserting chest tubes, harvesting saphenous veins, doing skin biopsies, and much more. PAs, for instance, can be trained on the surgical PA track, where what they do is more surgically oriented. What you are describing thus already exists to some extent; the only question becomes where to draw the line in terms of procedures. I would also note that surgery tends to be more competence-based than knowledge-based in how trainees are evaluated, because it has to be; no doubt the same would have to be true if such a thing as a surgical NP of the sort you describe were to be instituted.

      1. Andrey Pavlov says:

        I guess that is the real question – at what point do you delimit the scope of practice? I didn’t know that NP/PA’s could do things like PA catheters and saphenous vein harvesting unsupervised (actually, how can they harvest a saphenous vein without supervision? Isn’t the CT surgeon at the head prepping the chest at the same time? Unless there is some other reason to harvest that I don’t know?) since I have never seen them do that. Limits of my experience and all.

        The others seem to me to be a bit of a grey area. I guess I didn’t think of PA catheters, central lines, art lines, or chest tubes to be “surgical” because I do them and am not a surgeon. But really it is because they aren’t (necessarily) done in the OR. But I also see those things as rather minor with a pretty limited set of complications (relatively speaking of course). A chest tube can obviously be very involved, but in that case I can’t imagine the NP would be there alone without a physician. Patients with small pneumos can have chest tubes placed to go home with and discharged from the ED, so I can see that happening.

        I guess in my head it all boils down to the idea (right or wrong) that these are all procedures that are done outside the OR and no matter WHO makes the complication it can either be handled right then and there by anyone or will need to be rushed to the OR and a surgeon take over regardless. However a procedure actually in the OR to begin with strikes me as different (though once again, maybe I’m wrong). In that case you are vastly opening up the amount of complications and issues that can happen and things can get very complex very fast.

        What do you think about NPs doing things like lap chole’s or lumpectomies or say total colectomies with stomas or ileorectal anastomosis for refractory UC? To my limited understanding things like that are fairly routine for surgeons, but I still view them as complicated enough that even though I have been first assist or primary surgeon on those surgeries I sure as heck wouldn’t come close to doing them myself. But perhaps a focused track dedicated to that would make things different? Or a “residency” period after finishing NP/PA school?

        Which then brings me back to the original question – how do we determine which surgeries are within the scope? And even trickier – on which patients? A lap chole on me is incredibly straightforward. A lap chole on a 350lb diabetic with poorly controlled hypertension and COPD is a whole different beast.

        1. David Gorski says:

          The PA I work with now used to be the PA on a cardiothoracic service of the local hospital. She floated Swanns, did chest tubes, covered night call, etc. Of course, PAs are by definition “supervised,” but surgeons didn’t watch her do several of the minor surgical procedures that she could do. I know that in some hospitals NPs cover night call for surgical services and can do common procedures like the ones listed above.

          1. GC says:

            Dr. Gorski, you list relatively quick and straightforward procedures but could, or more importantly, should NP or PA do certain surgeries unsupervised. Why shouldn’t they do your job, your surgeries?
            So far I have not heard how you are going to draw lines in the sand. What are the requirements for all the variables that come to mind. Do you leave the decision up to each practitioner to determine what they can or can not do? We don’t do that with MDs but this seems to be the system you are proposing.
            We are deconstructing the practice of medicine to such a degree that no one provides full care to the patient. Not too long ago surgeons were proud of their ability to care for their patients and medical conditions outside the OR. Now many have no issue handing over care to hospitalist so they can do more surgery. They are becoming surgery technicians and not clinicians.

            1. Beth Henson says:

              I would say the line is drawn quite clearly by our education and training. Nothing in my training as a FNP has prepared me to perform a lap chole or other surgical procedure in the OR. I have been taught simple outpatient procedures such as suturing, nail removal, skin biopsies, etc. I know acute care NPs are taught more invasive procedures such as chest tube insertion and central line placement. When APRNs speak of “expanding scope of practice” what we mean is that we want legislative barriers removed so that we may practice to the full extent of our education and training. It would be dangerous and unethical to practice beyond that. The more appropriate phrase would be “full scope of practice” since we would not be expanding the role we have been trained for so much as removing barriers that prevent APRNs from being fully utilized.

              1. GC says:

                Beth,
                I understand what you are saying and that is really a side issue. Just as I do not want the Pathologist delivering my baby I do not want a FNP to do surgery. Each needs to work within their training. However, my question is: How far can we expand the training of non-MDs? Is their any specialty that is too far and should those trained in such a way practice separately, or, should they work within a team led by an MD, i.e., the person with the most extensive training. I feel that surgeons feel somewhat secure in their control of who does surgery, i.e., only surgeons, but are only to happy to say how every other field of medicine can parsed out based on training that is less intensive and less lengthy than the MD who would normally provide care.

  13. RobLL says:

    There are advantages for everyone that all practitioners are under some oversight. As primary care generally is carried out by PAs and NPs (as I have experienced both with the VA and our local community clinic) I like knowing that they are responsible to someone in addition to myself as a patient.

    The specialty which does not exist, and for which I think there is a need is diagnostician, perhaps in a variety of fields – orthopedic, internal, dermal, pediatric and geriatric. Such a person could be part of the backup for PCPs for a fairly large city or region.

  14. Chris Hickie says:

    When I first finished residency, I worked at a clinic where there were APRNs and physicians. It was a big enough clinic that there were good and bad APRNs and good and bad physicians. I felt the good APRNs were on par with the physicians and I gave the not-so-good APRNs credit for at least consulting with the physicians when they were not sure about a diagnosis,–whereas the bad physicians just kept being bad without consulting anyone. In my own clinic, I do not have any APRNs, but I just helped one do her pediatric rotation at my clinic. I’ve also had med students and medical residents rotate through my clinic as well. I didn’t have to change for this nurse what/how I’ve taught to the physicians and she handled the material just fine. I also feel that nurses are much more tightly regulated by their licensing agencies, and much more likely to be subject to disciplinary actions for misconduct then physicians (which is a sad statement about many of the state medical boards in the US). As long as their training is sound, I have no reservations either about APRNs (or to put it more precisely, I have no more reservations about APRNs than I do about physicians–meaning both groups with have their goods/bads/uglies). I do also have to point out a spousal COI in that my wife is a nurse whom I suspect will someday go for her APRN (and if she does will do fine, because she’s clinically really sharp from all her years of being a nurse). And given there’s so much insanity and inanity coming from non-medically trained chiropractors and naturopaths (eg anti-vaccine lies and fear mongering), I also don’t understand why any state medical board is going to go all nutso over APRN scope-of-practice when instead APRNs should be viewed as fellow goody guys and gals.

  15. Beth Henson says:

    GC,
    I would say the limits would be placed by finances and practicality. A “surgical NP” would require the development of a new educational track for APRNs. Remember APRNs chose their specialty at the beginning of their education, so it wouldn’t be someone trained as an FNP performing the surgery but an APRN trained specifically for surgery. While possible, I think overall it would be too expensive and impractical. As far as I know there isnt a shortage of surgeons like there is with primary care providers, which is what most APRNs are trained in.
    Just as a pathologist would not deliver a baby for obvious ethical issues, lack of reimbursement, and legal repercussions from the medical board, an APRN would not practice outside their scope for the same reasons. Many states, however, place limits on what an APRN can do that fall well within their training and education. They also require formal collaboration with a physician that can cost the APRN 100s and 1000s of dollars. These collaborations usually consist of nothing more than the physician agreeing to sign a certain percentage of charts each month, often days or weeks after treatment. They have nothing to do with consulting another provider for help or referral. In some states a patient may not be able to receive a prescription, referal, or needed treatment simply because there is no physcian physically in the building. These are the barriers to practice that need to be done away with.

    1. CNA Journal says:

      I couldn’t agree more with what Beth just said. There are certain outstanding state-imposed limits that are obsolete and provide nothing but an additional burden and obstacle that must be met.

      These state restrictions must be addressed – or reviewed at the very least – if we wish to have a sustainable, competent health care model.

  16. Beverly Benmoussa, MSN, APRN, FNP-BC says:

    Senate Bill 2, in the sate of Michigan, does not call for expanding the scope of practice for APRNs. It is an effort to define in statue what is already practiced.

    For example, I am a family nurse practitioner. My scope of practice is defined by my academic education, clinical experience, and board certification. Currently, if I have a medical conundrum I seek expert consultation from an appropriate peer. In a state with full practice authority, if I have a medical conundrum, I seek expert consultation as well. Senate Bill 2 will not change what nurse practitioners do. We will do the exactly same thing. What it will change is the environment in which we can operate.

    The restrictive practice environment of this state prevents nurse practitioners from practicing in many settings. Many of these settings have an insufficient number of physicians and are considered medically underserved. As a matter of fact, if you look at a map, the majority of Michigan is considered a health professional shortage area. If there was full practice authority for nurse practitioners in the state of Michigan -as there is in many other states- there would be more practitioners in areas which are considered medically underserved.

    So in summary, the bill will not change what nurse practitioners do. It will change how we do it, and remove practice barriers which will improve access to care for a lot of people. Thank you Dr. Gorski, for your expert, accurate, and evidence based commentary.

  17. Mark Speechley, PhD (Epidemiology) says:

    If we started today to design the division of labor in health care, we would probably not end up with the existing set of health professions and their protected scopes of practice. And given the doomsday scenario of the aging Baby Boom, we simply cannot afford the status quo. Yet, strangely, one of the highest priority health policy research areas is also one of the least researched: which evidence-based health care tasks, procedures, and behaviors could be safely transferred from higher trained and expensive providers to lesser trained and less expensive providers? (A lot of primary care? Many births?) Which tasks and procedures should be supervised by a highly trained expensive provider, and which ones are kept under professional control purely for income enhancement? (Fee-for-service dialysis?) Which ones could be done as well by educated informed patients with the right technology? (Chronic disease monitoring?). Which ones could be done more quickly and with fewer errors by machines? (Reading medical images? Some diagnostic and treatment algorithms?). The professional associations will resist, using ‘public safety’ as the bogey man, not because they are evil but because protecting their professional turf is their main raison d’etre.

  18. alona says:

    Mr.Gorsky,
    You have an amazing skill to mock people and make people feel BAD!
    Stop your mockery and treat your anger,start educating yourself about the EARTH IS NOT FLAT!
    You are making mockery of Dr.OZ love for alternative medicine,even so all medical institutions today have departments of integrative medicine,reiki is being used in the cardiac care units with an amazing proven success .
    You making mockery of the countries ,like in your article”Azerbaijan is rich,now it wants to be famous” .
    I feel nauseated by you.
    Sincerely,
    the person who is looking with a pride to the other people success and vision.

    1. Chris says:

      Well, your rant would have more weight if you spelled Dr. Gorski’s name correctly, had used citations to prove your point and had actually read the above article. Hint: it was not about Dr. Oz and does not contain the word “Azerbaijan.”

      Otherwise, carry on. Your comment was fun to read.

    2. windriven says:

      @alona

      Mr. Gorski is a plumber in Hoboken. Dr. Gorski is the managing editor of SBM.

      It is a shame. No, it is an embarrassment and a crime against the citizenry that many medical institutions have departments of quackery.

      “You have an amazing skill to mock people and make people feel BAD!”

      No, this is how you make someone feel bad: you point out to them that they are an empty-headed twit, useless to themselves and a danger to those around them, someone so devoid of intellectual depth they couldn’t pass a urine test.

      Of course I would never say that about you. I’m just happy that your nares* point down instead of up or I’d fear you’d drown in the shower.

      *nares are those little holes that you breath through when your mouth isn’t open.

      1. MadisonMD says:

        Ouch!

    3. Sawyer says:

      WD and Chris:

      I really think we should stop responding to comments like this. I’ve been noticing a disturbing increase in these sorts of throwaway rants, and tempting as it is to go for the jugular, it doesn’t do any good. Unlike some of the more dedicated quacks that hang out here, there’s zero risk any intelligent reader is going to fall for alona’s nonsense.

      Except for those rubes in Ajerbaijan. They’ll fall for anything, right Mr. Gorksy? :)

      1. windriven says:

        True enough, Sawyer. Your point is well taken. And while I make no promises, I will pause and reflect before setting to the keyboard.

      2. Chris says:

        I also make no promises. I am just love it when someone posts something that has absolutely nothing to do with the article’s content. It is just too much fun to grab the low hanging fruit of inanity!

        Oh, and Windriven: It should have been “Mr. Gorsky is a plumber in Hoboken.”

        Dude, you need to maintain the warped spelling!

      3. windriven says:

        @Sawyer

        I’ve thought some about this and here’s where I get stuck:

        ” it doesn’t do any good. ”

        And the reason that I get stuck there is that countenancing idiocy in the service of decorum is how, in my opinion, we find ourselves with “integrative medicine” services in many top line medical centers and medical schools.

        We fret about what to call sCAM. Should we call it that or should we call it pseudo-medicine or should we call it something else. Why don’t we just call it bull$hit because that is what it is. It isn’t any kind of medicine, pseudo or otherwise. The least noxious of it is speculative experimentation without meaningful informed consent. And the worst of it is pure, cold fraud perpetrated on a vulnerable segment of the population.

        I don’t know if getting in the faces of shruggies, wooly thinkers, or alonas helps. But I do know that not getting in their faces doesn’t help. Res ipsa loquitur.

        1. Sawyer says:

          I’m on board with everything you said. Most of the time nonsense should be confronted, whether it’s from the die hard quacks or the more stoic shruggies. It’s just that there are certain, um, “special” characteristics of alona’s post that are already going to stick out like a sore thumb to any casual reader. She’s already shown how silly the critics of SBM are better than any of us can. At some point there’s nothing to be gained by throwing more salt on the wound.

          Ah, who the hell knows? I’m probably just as guilty of engaging people that do not deserve any recognition, so carry on.

          1. windriven says:

            @ Sawyer

            And I agree that there are situations where the inanity speaks for itself so clearly and so loudly that responding to it is superfluous and possibly counterproductive.

          2. Andrey Pavlov says:

            @sawyer:

            We all do it. I’m probably particularly egregious at it. Though recently I’ve had less time for it and tired of it. IMO, it is your time to spend as you wish. When I did have the motivation for it, I found it to be both educational (as I actually took the time to learn the topic and formulate thoughts on it) and cathartic. The first part actually makes a difference IRL. Since I have written out my thoughts on so-called CAM so many times in so many ways from so many angles, when it comes up IRL I don’t have to fumble around and try and remember certain points or ideas. I can be much more succinct, hit the major points to drive the ideas home, and if necessary can expound ad nauseum. All thanks to having argued it out here over and over and over again.

        2. PMoran says:

          “We fret about what to call sCAM. Should we call it that or should we call it pseudo-medicine or should we call it something else. Why don’t we just call it bull$hit because that is what it is.”

          Won’t it depend upon who you are talking to and what you would like to achieve from the exchange?

          1. windriven says:

            Peter, tone matters and should be calibrated to the situation. I am sometimes guilty of making assumptions about my interlocutor that are wrong and that is something I’ve resolved to be more careful about.

            But I am becoming increasingly reluctant to use collegial and inclusive words and phrases to describe quackery. Alternative medicine. Integrative medicine. Pseudo medicine, complementary medicine. Reiki is not medicine regardless of what adjective precedes it. Calling it any kind of medicine gives it a dignity that it does not deserve. I am deeply troubled by the ubiquity of so-called CAM programs at many, perhaps most, of our first line medical schools and medical centers. It is intellectually dishonest and it is a monumental disservice to the general public as it suggests the imprimaturs of science and medicine on something that isn’t.

            Not everything that isn’t medicine is quackery. But that doesn’t make those things ‘sorta’ medicine. It makes them speculative interventions that can and should be explored in a scientific setting with clear and complete disclosures to patient populations and under the auspices of the relevant IRB. Vitamin E for Alzheimer’s is a fine example.

            I apologize Peter. This is running very long for being such a simple idea. Science based medicine is the three steps forward. Quackery is one of the two steps back. Calling it by a non-confrontational name doesn’t make it better and it doesn’t hasten it’s demise.

            1. Andrey Pavlov says:

              I actually will take a moment to agree with Peter here.Our tone, tack, and word usage should vary depending on context. Which is why we can – and should – adopt a “hard line” here at SBM as an unflinching source of information, but we can soften and amend our stance in real life as the situation warrants. In the past Peter and I have argued this exact point and it seemed to me at the time he did not seem to understand that you can and should take a different tack in person than online. Now he seems to understand that but apparently still believes that whatever tack we take online here is inappropriate and on that we will continue to disagree.

              Where I will agree with you windriven is that while I find it uncommon to be apropos to call it “bull$hit”* I have fallen into the habit of calling it “so-called CAM” or “so-called alternative medicine”, etc. Basically I add the “so-called” in front of it to immediately show my disdain for the term and either allow conversation to happen or allow the interlocutor an opportunity to ignore and move on. Only if it is absolutely pressing (e.g. it is something that will be actively done or recommended to the patient and has a likelihood of harm) do I force the issue. And even then, thanks to my low station in the medical hierarchy, I must do so carefully and in a questioning manner and ultimately produce papers to demonstrate my point (and Peter has demonstrated why I must do it this way in real life).

              * (though there are circumstances where I do and specifically for effect – it shocks the person into questioning me and precipitates the conversation; the risk you run in doing that is they pre-judge you as being “closed minded” and having an agenda/vendetta and that essentially shuts down all meaningful conversation. So I pick those situations carefully – either when I have little time but need to make the point or, more commonly, when the person knows me to some degree and already feels that I am a knowledgeable, informed, kind, and caring individual.)

              1. windriven says:

                I don’t think we disagree, Andrey. I do think we probably would put the line in different places.

                I come at this from a different perspective. You are a physician and have professional obligations to your patients and your colleagues.

                I’m just a loudmouth from the great northwest who is offended by the manipulation of vulnerable people by dreamers and con artists – and by their enablers who fail to shun and actively discredit what they know to be wrong. Interventions that aren’t medicine are dangerous and they are expensive. As a nation we spend twice what our neighbors pay for healthcare yet only a fraction of our population gets decent care.

                Eliminating quacks will not solve all the problems – but it will eliminate one.

            2. Andrey Pavlov says:

              @windriven:

              I didn’t quite say we disagreed… I did say that I agreed with Peter. Which I wanted to make a point of since we so often disagree.

              I absolutely agree with what you are saying and yes, my role in my profession and in society is indeed different from yours. No matter how much I wish it I can never “stop being” a physician, no matter in what social or public sphere I am in. Hell, last night I was having drinks at Brother’s Three (my favorite local dive that I frequent so much I don’t ever need to order) and ended up doing a quick shoulder exam on a patron because the bartender knows I am a physician. It almost didn’t matter what I found on my exam – my response would have been the same: “Seems to be a bruise with some soft tissue injury that you say is getting better, it should continue to with ice and some NSAIDs, but if it gets worse or is bothering you a lot you should go in for a visit with your doctor.”

              The point is that outside of my smallest and closest circle of friends, I am always “the doc.” And even there that isn’t always the case. Over Christmas a friend’s grandmother ended up in the ICU with malignant hypertension and they asked me to explain what that meant and what the doctor was telling them.

              So you are right. You get much more latitude in what you say and when. But I still reserve the right to hold a hard line on line :-D

              1. windriven says:

                Agreed,

  19. BurnOut says:

    I’m late to the discussion, but I think this article brings up a question: do we need primary care physicians any longer at all?

    If the evidence supports that outcomes are the same for NPs, then perhaps the best course is to phase out physicians in the field.

    The decision to allow independent practice by NPs, who have a shorter and less expensive course of training, should eliminate the primary care physician anyway. Why would a good physician spend far more to be educated and spend extra years training in residency while being paid poorly, when there is an alternate path to the same place?

    1. windriven says:

      “do we need primary care physicians any longer at all?”

      Yup. NP does not equal MD. Advanced nurse practitioners are well trained in specific areas. MDs have much broader comprehensive training. The idea should not be to eliminate MDs but to free them from mundane tasks and allow them to focus on more complex conditions.

    2. We definitely need PCPs, but we also need NPs. We need all hands on deck sir.

  20. Mark Speechley says:

    IMO family docs have tried to do it all: continue their expertise in front-line biomedicine while also embracing psychosocial issues. Family docs are expected to have expertise in everything from heart disease and cancer and diabetes to depression to substance abuse to elder abuse to primary and secondary prevention to family health to referrals to follow-ups to … well, everything. I think medically trained front-line providers have a essential role to play in practising evidence-based diagnosis and pharmaceutical treatment of ‘diseases’. My hunch is that there are probably things that MDs can do better on average than NPs, things at which they are equivalent, and things NPs (or psychologists, or PTs) are better at. Reimbursement could be on the basis of complexity of the task, the potential for harm if it’s done wrong, and the competence with which it is done as judged by measurable outcomes. These are answerable research questions with high policy relevance. Huge complex expensive ethically challenging politically opposed RCT anyone?

    1. Andrey Pavlov says:

      The issue I see in this question of NP replacing PCP is the approach to the undifferentiated patient. Once a patient is known to be seen for heart disease a specifically trained NP can very easily take over management and subsequent diagnoses. But for the completely undifferentiated patient who just walks in the door, you simply need a very broad base of knowledge and understanding in order to properly diagnose and more importantly rule out diagnoses. It is also important to know when you can send you patient home with a reassuring pat on the shoulder that everything will be fine. This is what makes being a PCP so genuinely difficult (and why chiros simply cannot do it) – the undifferentiated patient.

      Granted an NP or whatever could probably do OK at this because most undifferentiated patients are typically fine or have self limiting conditions or conditions that are chronic but will eventually get picked after repeated complaints. It is the ones that slip through the cracks there that are the issue and I posit that you need a significant amount of knowledge and training to do it well. There is a reason that a cardiologist would not just go back to doing primary care even though the first half of his training technically made him competent to do so.

      An NP would be – and is – an invaluable asset to a PCP and can effectively multiply his or her productivity without decreasing quality of care (in fact I would argue it would increase the quality of care). But I am hard pressed to think that a “PCP track” for an NP would be significantly different than getting an MD and doing an FP or IM residency. Granted we could tweak things a bit in med school to cater more specifically to a PCP career, but we actually already offer that in many schools and post graduate training programs. Maybe more needs be done in that regard, perhaps with incentives to those who sign up specifically for PCP track education, but creating a whole separate paradigm for PCP NP’s seems not the right path to me.

      I could be wrong though.

    2. Harriet Hall says:

      I must speak out to defend my specialty: family medicine. I chose it because I saw patients who fell through the cracks of the specialty system. Example: a patient with headaches was seen in internal medicine and referred to neurology and psychiatry; they didn’t find a neurologic or psychiatric disorder and everyone had essentially told her “I can’t help you; go away.” She had nowhere else to go but to me, and I was able to manage her overall health care and work with her to cope with symptoms that didn’t fall into a diagnostic category. A family physician can take primary responsibility for a whole family and act as healthcare manager and traffic director/interpreter of specialty consultations; the focus is on the whole patient in the context of the family, psychosocial, and other factors. I think the broad spectrum of education and the “holistic” perspective of a family physician brings something to the table that other practitioners don’t bring. That said, I worked with and helped train family practice nurse practitioners and PAs and I thought they did an excellent job. The ones I worked with had good judgment: they were very aware of what they didn’t know and were quick to consult an MD when they got beyond their depth. And they tended to spend more time explaining things to patients and were not bored with the routine cases. Patient satisfaction and quality of care were high. I think a team approach would be ideal, with an FP in charge and a “medical home” for every family unit.

      1. Andrey Pavlov says:

        This seem concordant with my thoughts Dr. Hall. I think that much of the work of an FP can be done but NP/PA but not all. We don’t need ONLY physicians to do primary care/FP but I don’t think we can relegate it ALL to NPs either. Having the FP be the “team captain” with a few NPs/PAs seems like a sound model to me.

      2. Beth Henson says:

        I think I was in agreement with you up until the part where the FP was in charge of care. To me this takes away from the importance of providing patient centered care. A well informed patient should be the one making decisions about their health – emphasis on well informed. This would allow more fluidity in the multidisciplinary approach to health care since different disciplines could take the lead as the patient felt the need.
        It reminds me of a story I heard when I first started school. A group of Providers were going to start a clinic in an inner city urban desert. There were many health needs – lack of access to fresh fruits and veggies, poor diet, high rate of violence, DM through the roof. Many groups had tried and failed to help so there was a lot of hostility going in. The providers asked the community what they needed, expecting answers to center around better health care, and promised to deliver. The community responded that they needed a traffic light and crosswalk because of so many accidents that happened in the area. I use this story to remind myself that if I don’t place what the patient needs first (regardless of where it falls on my priority list) then I’ll never be able to help them and to understand why making the patient the leader of the health care team is so important.

        1. Andrey Pavlov says:

          I think you misunderstood me Beth. I didn’t say that the FP was “in charge of care” in the sense that you are describing. (S)he is not the final arbiter of everything and everyone else is pandering to him/her. I used “team captain” specifically since that is exactly what I mean. There needs to be a person to organize, have a good overview of the “field”, and be the one to make the final decision in those cases where there is disagreement and no clear answer is forthcoming but a decision needs to be made.

          But just as a good team captain of any sport values all the players and participants in the team, so should the FP as team captain. All input, help, and decision making capacity is valuable. And a good leader delegates, trusts, and doesn’t micromanage. But we still need someone who is the team leader/captain.

        2. Harriet Hall says:

          The FP is, as Andrey said, like a team captain, coordinating all healthcare but not dictating what the care should be. In no way does that imply paternalism. Family practice, since it is attuned to the whole patient, is particularly sensitive to the patient’s individual philosophy and wishes. In one sense I agree that the patient should be the one making decisions about their health: that’s the ethical principle of autonomy. But in another sense, I think the goal should be joint decision-making where both the patient’s wishes and the doctor’s expert knowledge play a vital part.

          1. Andrey Pavlov says:

            Somehow I am not surprised we agree here Dr. Hall ;-)

            But yes, precisely. Coordinating and making the final “tough” decision when necessary is the major role of the FP in this scenario. But this is true of any medical team. Not just “even” in the ICU, but especially in the ICU the input of every member of the team is valuable and the patient/family wishes and desires are paramount. The most anxiety provoking moment I have had in my medical career so far is when I had a particularly ill patient in the ICU and I proposed a particular plan of care. The PharmD on our team disagreed and proposed literally exactly the opposite. In all honesty, there was simply no way to tell who was right at that moment. We talked about it for a while and at the end the attending said that since I was the one training to be the physician that the plan was entirely up to me – my word was final and that is what we would do. Now that is real pressure! I stuck with my guns and it turned out to be the right move.

            The two key lessons from that were 1) to learn how to handle that kind of responsibility and 2) to realize that I just as easily could have been wrong and not get cocky about it but always work to make the best decision possible with the information available.

            But that is the role of the physician as team captain – at that point two completely opposite plans were equally feasible. And if either one was wrong it would make the patient worse*. Somebody has to make that decision and it seems reasonable to me that said someone should be the MD, not the NP.

            *That is why we have the ICU though – sometimes we need to “try” something and watch the patient very carefully to see what happens. That is why knowing the natural course of disease and all the relevant pathology and pathophysiology is vital, so you can clue in to the earliest signs that you are right or wrong and adjust accordingly.

        3. weing says:

          @Beth,
          Good. Could I have some vicodin? I don’t tolerate NSAIDs.

  21. Mark Speechley says:

    Strongly agree. As a non-MD who strongly supports the profession, I think medically trained front-line providers have an essential role to play in practising evidence-based diagnosis and (mostly) pharmaceutical treatment of ‘diseases’. IMO family docs have tried to do it all: continue their expertise in front-line biomedicine while also embracing psychosocial issues. Family docs are expected to have expertise in everything from heart disease and cancer and diabetes to depression to substance abuse to elder abuse to primary and secondary prevention to family health to referrals to follow-ups to … well, everything. My hunch is that there are probably things that MDs can do better on average than NPs, things at which they are equivalent, and things NPs (or psychologists, or PTs) are better at. Reimbursement could be on the basis of complexity of the task, the potential for harm if it’s done wrong, and the competence with which it is done as judged by measurable outcomes. These are answerable research questions with high policy relevance. Huge complex expensive ethically challenging politically opposed RCT anyone?

    1. Mark Speechley says:

      Apologies – didn’t know my first post was posted….

  22. Joe Smith says:

    Read your old article on Dr. Oz. I couldn’t agree with you more. This guy was making mega-millions before he met Oprah. Now, I’m sure he makes mega-mega-millions. He must come up with new material for his very popular show, on a daily basis, and it’s truly disgusting to see how he regularly promotes pseudoscience and snake oil sales. When I switch on his show to see what nonsense he’s into, for the day, I can usually stomach about a minute, or two, at the most. “Today, you won’t want to miss the secret food you MUST eat to stay healthy. It is the most important show we’ve ever done!” Trouble is, the next day, that day’s show will be the “most important.” The guy has no shame, no integrity. He’s a whore for the spotlight and his billion dollar income. It just makes it worse that he has rock-solid credentials as a physician and surgeon.

  23. Smitty says:

    Being a patient, here are my experiences. My retired internist told me, most of my job is to guide your medical care and coordinate it. I take care of the small/relatively small stuff. He was fabulous and did his job well. He took care of me and my family. I’m hoping that his replacement will develop his skill. My experiences with NP’s has been way less than optimal. Out of four visits with an NP I have had a good result with only one. Oddly enough, it was through a drugstore NP. The remainder were total disasters. Two wound up resulting in having to have surgery due to ignorance or whatever.

  24. huggs says:

    I appreciate your opinion and supporting data, Mr. Gorski, and would like to add the Cochrane review from 2013, Midwife-led continuity models versus other models of care for childbearing women.

    In the review, Jane Sandall, of the Division of Women’s Health at King’s College London, London, United Kingdom, and colleagues, examined 13 studies involving 16, 242 women comparing outcomes of care when randomized to be delivered by a midwife led continuity model of care with that delivered by a doctor led or a shared model of care in which both doctors and midwives provide care.

    “They found that women who were randomised to care delivered under a midwife led model were less likely to undergo spinal or epidural regional analgesia, to have vaginal birth with instrumentation with forceps or vacuum, or to give birth prematurely. Women who had been randomised to the midwife led model of care were also more likely to experience a spontaneous vaginal birth.

    The researchers found that there were no statistically significant differences between the groups for caesarean birth, overall fetal loss, or neonatal death.” BMJ

  25. WilliamLawrenceUtridge says:

    “hey found that women who were randomised to care delivered under a midwife led model were less likely to undergo spinal or epidural regional analgesia, to have vaginal birth with instrumentation with forceps or vacuum, or to give birth prematurely. Women who had been randomised to the midwife led model of care were also more likely to experience a spontaneous vaginal birth.

    Why is this a good thing? If there are no differences in terms of caesarean births, fetal loss or neonatal deaths (assuming the definitions of those terms were common across all studies), doesn’t that suggest that it could also be read as “thousands of women suffered unnecessary pain with no improvement in maternal and fetal outcomes”?

    The fetishization of natural child birth and suffering through the pain of labour is something I will never understand.

    1. Not likely. Lack of interventional procedure cannot be equated with pain levels and their necessity. If this is a specific area of interest to you, you may want to more closely examine standardized quality measures associated with deliveries as well as secondary outcome measures such as patient level of satisfaction with birth, time to feeding, etc.

      1. WilliamLawrenceUtridge says:

        All I know is – anyone who places their “birth experience” above, or even equal with, the health of mother and child isn’t someone I am likely to respect.

        Birth is an inhernetly painful experience. Spinal blocks and epidurals are low-risk interventions that eliminate pain. The pain is not a necessary part of childbirth, it is purely due to the fact that the tissues are being (of necessity) traumatized as the human pelvis is poorly-adapted for childbirth (it’s a compromise between bipedal walking efficiency and having to push a baby out of it, and does neither optimally). Blocking the pain, therefore, seems like a good idea – it removes the least pleasant part of the whole process.

        Why midwives think natural, painful childbirth is better, I’ll never understand. Is it because they can’t undertake the procedures necessary to reduce pain? Because it gives them a wedge to drive doctors and pregnant women apart, and thus generate more revenue for themselves? Because they are uncritically accepting of the naturalistic fallacy? I don’t know, but it just seems stupid.

        1. mousethatroared says:

          WLU – Epidurals aren’t done by OB’s either. They are done by Anesthesiologists or Certified Registered Nurse Anesthetists. When a nurse midwife is working in a hospital setting, and I believe the majority of certified midwife do work in hospitals, I would think that they have access to the anesthesiology staff. Do you have evidence that certified nurse midwifes are not offering appropriate pain management?

          You seem to be suggesting their deliveries are somehow less safe, yet you quoted an except that says there was no difference in neonatal deaths or fetal loss.

          1. WilliamLawrenceUtridge says:

            In the US there are multiple tiers of midwives. One flavour is basically a nurse who specializes in child birth (certified nurse midwives I believe). That’s great – science, supervision, education, reason as best we ever see from a medical professional. The other type (direct entry midwives I think?) just requires a high school diploma, a weekend course, and usually embraces the worst of the evidence-free nonsense and quackery that gets people killed. This includes nonsense like “birth doesn’t actually hurt, c-sections are evil, anyone can breastfeed (and if you can’t, you aren’t trying hard enough), birth is naturally safe for baby and mother, vaginal birth after c-section is just as safe as one without a c-section, etc.”.

            The skeptical OB writes on this topic a lot, and her assessment of the evidence is that home births, many of which are overseen by the lower-tier of midwives, are many times more dangerous than hospital births – with low risk, midwife-supervised home births being an order of magnitude more dangerous than a high-risk hospital birth. It’s obviously complicated, there’s a lot of overlap that muddies what you criticize (i.e. home birth is associated with midwives but not an exact overlap, so is it midwifery or home birth that is dangerous). Definitions are slippery and often substituted one for the other, making analysis and discussion more difficult. Direct entry midwives do tend to oppose any sort of pain management and are big into things like hypnobirthing and water birthing (giving birth in a combination toilet and blood bag? Great idea! Maybe your baby’s first breath can be of this feces-and-biohazard soup!).

            I have less issue with CNM, though personally I would never want my baby and partner’s care managed by anyone but an actual doctor, with assistance from science-based nurses. But as far as I’m concerned there should be a special place in hell reserved for direct entry midwives, the same place they send Max Gerson, Hulda Clark, Stephen Gonzalez, Stanislaw Burzynski and every homeopath, ever.

            1. mousethatroared says:

              WLU – “In the US there are multiple tiers of midwives. One flavour is basically a nurse who specializes in child birth (certified nurse midwives I believe). That’s great – science, supervision, education, reason as best we ever see from a medical professional. The other type (direct entry midwives I think?) just requires a high school diploma, a weekend course, and usually embraces the worst of the evidence-free nonsense and quackery that gets people killed.”

              David Gorski’s article is about advance practice nurses. Isn’t that the topic? Or do you the Cochrane review was based on midwifes with only a high school degree and week-end course? If so, the results are shockingly good. I would have to commend the high schools and week-end courses.

              The Conchrane review seems to contradict your speculations.

              http://apps.who.int/rhl/reviews/CD004667.pdf

              1. WilliamLawrenceUtridge says:

                I wasn’t thinking specifically of Dr. Gorski’s original post when I wrote my reply, my net was cast to reference any midwife who urges birth without pain relief – and direct entry (?) midwives are the worse for it. They also tend to be understudied because their profession is of borderline legality. Indeed, one organization (MANA) collects outcome data on their own “professionals” births, but refuses to release it publicly presumably because the results are horrifying.

                CNM – great, very little problem there (though if they still support home births, I think that’s a terrifying idea). Direct entry – should be completely illegal. And I bet if you teased out all of the data on the midwifery research, it would study the former, not the latter (no reference to “direct entry midwives” in the WHO document, one study explicitly discussed CNM, but you’d have to dig a lot more to find out).

                And again – if the health, safety and outcome data are identical, but the only differences are “more unmedicated births and more vaginal deliveries”, why is that a good thing? If the same number of healthy babies, living mothers and complications are found in each outcome, why are the differentiated items (greater pain, less surgery) “better”? Particularly the pain part!

              2. mousethatroared says:

                WLU “And again – if the health, safety and outcome data are identical, but the only differences are “more unmedicated births and more vaginal deliveries”, why is that a good thing? If the same number of healthy babies, living mothers and complications are found in each outcome, why are the differentiated items (greater pain, less surgery) “better”? Particularly the pain part!”

                You are making the assumption that less pain intervention means more pain. The other explaination is that there was less pain to control. Perhaps that is the case. The review suggests that women’s satisfaction with pain control was slightly higher with midwife led care than other models.

                Also, you were mistaken earlier when you speculated that MLC resulted in longer labors. The review suggested they averaged the same.

                You know, I doubt the Cochrane folks are uncaring idiots, they did look at the outcomes you are concerned with. It’s just that the results don’t seem to match your expectations.

          2. nancy brownlee says:

            @Mouse- My epidurals were performed by my obstetrician. That was (ahem) some time ago- and he was a surgeon- but, still. Is that unusual?

            1. mousethatroared says:

              Maybe others will correct me if I’m wrong. I have a family member who is an nurse anesthetist – mostly OB these days. I was under the impression that the anesthesia department generally did all the OB anesthesia – epidurals and otherwise.

              1. weing says:

                “I was under the impression that the anesthesia department generally did all the OB anesthesia – epidurals and otherwise.”

                That’s how it was when my wife last gave birth. That was almost 21 years ago.

              2. Harriet Hall says:

                Who provides what anesthesia for childbirth varies with training. It is certainly not limited to anesthesiologists. As a “rotating 0″ intern in 1970-71, I routinely did spinal anesthesia (saddle blocks) on OB patients with no other doctor in the room to supervise. I also provided paracervical/pudendal anesthesia with scary long needles. In 1982 my obstetrician did my epidural. In 1984 a different obstetrician did a paracervical/pudendal block that provided as good pain relief as the epidural had.

              3. Chris says:

                For my boys, who are in their early 20s, I only had a conversation with a nurse anesthetist. The thing was that he would take too long to explain the epidural, and hen I would be too dilated.

                My daughter was born about a forty five minutes after arriving to the hospital, a labor that took less than two hours. There was no time. Our family doctor arrived just in time to catch her, otherwise it would have been the nurse.

                So I am amused when some crunchy person tells me that my oldest’s neonatal seizures were caused by the epidural. To which I have to respond, I never had one.

          3. WilliamLawrenceUtridge says:

            Also, I know that the midwives don’t do the epidurals, the anaesthesiologists do. The role of midwives, as suggested by the studies (and the delightful snark of the skeptical OB’s site), would seem to be discouraging anaesthesia rather than delivering it. And somehow it has spread through the popular discourse where “giving birth without pain relief is how real women do it” is a thing.

            And don’t get me started on the whole bottle/breast thing.

            1. mousethatroared says:

              WLU – Neither midwives or OBs typically do epidurals. If you knew that, then why did you insinuate some plot by midwives to discourage epidurals because they can’t do them?

              Clearly you can have the preference you like in medical care. But it’s not science based or particularly credible to smear the reputation of a group of professionals who have done the appropriate education and clinical hours to become certified to deliver a medical service safely and effectively, without evidence, while conflating them with a group far less qualified people with a similar title.

              1. WilliamLawrenceUtridge says:

                MTR, you might have a point about certified nurse midwives. But as I’ve said before – direct entry midwives do not do the appropriate education and clinical hours to deliver anything like safe and effective medical care to a pregnant woman. I made the point that I distinguish between the two and have much less issue with the former. The latter, untrained, weekend-course, high-school-only direct entry midwives are parasitic on the reputation and training of CNM, and should be charged with practicing medicine without a license as far as I’m concerned.

                I also question the validity that “reducing the amount of pain control” is a goal we should work towards. I question the natural child birth/home birth movement as a whole, based as it is on the assumption that childbirth is a naturally safe, painless procedure. I question whether the Cochrane review distinguished between CNM and direct entry, and I doubt the latter would fare well in any scientific study.

                Also, I never claimed that midwives or OBs did epidurals. I criticized (perhaps implicitly or explicitly) the role of midwives in discouraging pain control as a goal. I don’t care which type of midwife discourages it, I think it’s a bad idea. Here I shade from any evidence basis into a personal opinion, but I’m pretty comfortable with it.

    2. brewandferment says:

      why do people run ultramarathons and climb Mt. Everest? Would those things (or even a marathon/half-marathon) have anywhere near the bragging rights if you could just hop right out and do it with no preparation and no pain…

      I was hopelessly inept at all sports as a teenager and I am glad that I ended up with one physical talent–easy pregnancy and delivery–obviously not one I had any control over nor that could be improved with practice….

      But the birth of kid #2 was not especially painful, just lots of work near the end(which wouldn’t have been helped by an epidural and indeed may well have been hindered, it was such a big kid and maximum mobility went a long way there, as well as food and hydration for energy). And kid #3 was positively low on the pain scale–and by the time I’d have gotten to the hospital if that’s where I had been delivering, I would have been too far gone for any pain procedures anyhow. Afterbirth with kid #3, now THAT was painful for a couple of days running (not the entire time, of course, but as the pain meds started to wear off, sheesh was it tough until the next dose kicked in.)

      I’m no stoic–but I still say it was much less painful having kids with no meds than the pain of a broken femur, by a long shot! Not everyone has the same pain tolerance levels, or even pain sensations.

      1. WilliamLawrenceUtridge says:

        Running a marathon is usually not lethal, while childbirth (and climbing Mount Everest, which I also have no respect for considering it’s generally only done with supplementary oxygen and sherpas doing most of the work) is. The most dangerous day for mother and child both. While I guess I can respect running a marathon (to a degree, in my mind it’s far more exercise than you need to be healthy), suffering pain merely to suffer pain just seems, pardon my language, dumb. Why would anyone be proud of getting a filling drilled without novocaine? I’ve had it happen, it’s something I complained about, not something I bragged about. Why would you be proud of having a limb amputated without anaesthetic, or suffering through a headache or arthritis rather than taking ibuprofen? I can understand being concerned with the adverse effects and risks of pain killers and doing without – but being proud? I don’t get it.

        And B&F, would you be as blase about it if it were not easy, if it were agonizing? If giving birth were significantly more painful than your broken femur? Did you suffer your broken femur without painkiller? I would suggest that the two situations are different, in your case alone, because for you childbirth was not painful.

        I dunno, I wonder at the double standard – why childbirth without pain is somehow something to be proud of, while dentistry without pain is seen as stupid.

        And again, separate the experience without painkillers from the concern over the risks of painkillers. I can more reasonably accept someone not taking painkillers because of concerns over adverse effects, that’s a somewhat rational response. But desiring to experience pain? Nope, that’s beyond me.

        1. brewandferment says:

          ok, guess I was being a bit too flippant. I was trying to find an analogy of things that men do which are painful for no really good reason than because it’s there. I did say “ultramarathon” you know, the ones that are 50 or 100 miles, at least one in Death Valley in the summer, or Ironmans. I hear you about Mt. Everest, so replace with Mt. Hood, Mt. Whitney, any given Rocky Mountain (US or CA), or for that matter, the Adirondacks in the winter.

          I didn’t say that I was proud of pain for pain’s sake (marathons hold no interest for me, let alone an Ironman) but people do engage in risky activities just for bragging rights, which do pose a serious risk of death (mountain climbing, skiing in avalanche prone areas) and/or which often produce quite a lot of pain either in the preparatory phases or as a result of the event (listen to any marathoner describe their recovery afterward!) It was just to answer the question about bragging about pain, women aren’t the only ones! ;->

          Really, the main reason for mentioning my broken femur was as a point of comparison–yes, I had pain meds but after I was discharged (it was a surgical repair), I don’t think I had much available to me. Not sure just why, but my parents are dead so I can’t ask them. It was also an utterly different kind of pain.

          Yes, side effects of medicines were and are a concern for me–not as much about risk as personal dislike of the side effects (groggy, in case of epidural the catheterization, food/water intake restriction, lack of mobility, and so on) and just the fact that I found ways of managing the labor pain that made meds unnecessary.

          Just to be clear, I’m glad that women who need or want labor pain meds have them, but for those who don’t (for whatever the reason) remember it’s not always a pain fetish. Working with your body during contractions and being able to move around, change positions, and so on–those are positive reasons to avoid pain meds and shouldn’t be discounted. That mobility, for example, can actually help prevent labor stalling and keep from needing a Csection, which is a good thing.

          So sorry if I came across as callous, wasn’t my intent. I better stop now so I don’t end up chewing on my toenails.

          1. WilliamLawrenceUtridge says:

            Perhaps the analogy would be “running an ultramarathon without bandaids over your nipples”? I don’t know if the comparison is fair, as there really isn’t a way of running such a race without experiencing pain, whereas there is a way of delivering without (or with reduced) pain.

            Again, I suppose I have less problem with people who don’t get the pain medication out of a fear of the risks (no matter how irrational I feel this to be) than with the ones who seem to think they “aren’t a real woman” unless they think they go through unmedicated childbirth.

            Of course, I’m not a woman at all. Though Mrs. Utridge agrees with me.

            1. brewandferment says:

              I think it’s just a different kind of competitiveness to make oneself feel special, but both genders are guilty of it. Ironman competitors (male and female alike) surely feel a certain sense of superiority over “just marathoners” who feel likewise about 5K runners. Would men play tackle football if there were no pain involved? or ice fish? ride motocross (powered or pedal) and not show off their injuries with pride about how tough they were? rugby seems like purely for the purpose of inflicting pain and injury to revel in by all parties!

              As to pain management, my point just is that there ARE ways to reduce the pain that don’t always involve needles and medications. I’ve never had an epidural so I wouldn’t know, but I’ve heard it described as making your legs feel like dissociated logs attached to your numb pelvis. I know that many women do fine with that but I couldn’t comprehend that as better than being able to move around, eat, drink, sit in a warm tub, avoid a catheter, etc. Like I said, in some cases it’s less about risks than personal preferences, and if it is a woman’s preference to manage with non-medical methods because she doesn’t like the side effects, then she’s not wrong for choosing that for those reasons. And I don’t think it’s helpful to first time mothers-to-be to frighten them with tales about how dreadful the labor pain is; for some it is (especially when pitocin is involved) and for some it isn’t. For some it might not be if they weren’t all tensed up with anticipation of pain.

              1. Chris says:

                “I’ve never had an epidural so I wouldn’t know, but I’ve heard it described as making your legs feel like dissociated logs attached to your numb pelvis.”

                And neither have I, but only because of long winded nurse anesthetists.

                Though it may not have mattered too much since I have dull nerves. I am one of those people that literally cannot feel certain injuries, and that is not always a good thing. I get bruises and cuts with no clue how they happened. Though it is not perfect, when I am in pain I am the most horrible person to be around.

              2. Harriet Hall says:

                In case you may have missed it, I wrote about epidurals and pain relief in general at http://www.sciencebasedmedicine.org/childbirth-without-pain-are-epidurals-the-answer/
                My legs did not feel like logs after the epidural, but after a very effective paracervical/pudendal block I had trouble using my legs when I first tried to get up to go to the bathroom. Epidurals are very safe, and some providers use an improved technique, a “walking epidural” that overcomes your objections about mobility. And people forget that there are also risks associated with untreated pain.

    3. mousethatroared says:

      “Why is this a good thing?” Don’t we usually try to avoid surgical interventions, when possible? From what I’ve hear, often the recovery time is longer after cesarean and then there’s a scar, often easy to hide, but – and greater cost.

      1. WilliamLawrenceUtridge says:

        In-hospital is a day longer for a c-section; at home recovery is also longer. But in some cases is the best choice (given odds and uncertainty of course) for a pregnant woman delivering a live baby rather than a corpse, and surviving the birth herself. Doctors do try to avoid unnecessary surgery – but they base their decisions on the safety of mother and child (and ultimately the risks of c-section versus vaginal delivery are different, but about equal). Meanwhile there are mothers who fetishize the experience over their own health and the health of their child, who oppose any form of medical intervention a priori without an appreciation of the evidence, and are disappointed when at the end of their labour all they got was a healthy baby and 50 more years of life to live. Ugh.

        And what costs more than a c-section? An emergency c-section with significant complications because it occurs more quickly, after considerable exhaustion and stress on the baby, requiring supplementary and emergency measures to preserve the life of mother and child.

        And really, I’m more discussing the pain aspect.

        Finally, my parsing of the text is that outcomes were basically identical, the features that were different were the amount of pain control and use of instruments. So – both groups resulted in equally healthy mom and baby. The only difference was how they got there. So that suggest neither option is superior in terms of objective endpoint, but all the interventions you take out are ones that can make birth faster and less painful. Why is that better?

        1. Dave says:

          The most important outcome for a pregnancy is a healthy baby and healthy mother.
          Nurse midwives generally take care of low risk pregnancies. If something doesn’t go right or if the pregancy is high risk the is generally be referred to a center. If the mother’s experience at centers is suboptimal we should work to make it better. However, the worst experience would be a dead baby or mother.

          I’m a little surprised at the results of the Cochrane review. I’ve seen a few studies in the BMJ in the past few years, one from the Netherlands and one from GB, that did not paint as rosy a picture. This isn’t my field so I dont follow that literature closely. I also think the mother’s decision might be guided by location. A home delivery might be less risky if your home was a few miles from a center, more risky if you lived on a ranch in Wyoming 100 miles from a center.

          1. mousethatroared says:

            Agreed Dave, The Cochrane review and recommendations was based on low risk pregnacies with licensed midwives led care delivering in hospitals.

            It would in no way be representative of home births, less qualified midwives or higher risk pregnancies. But, it seems to fit well within the context of David Gorski’s article.

            Personally, not being a childbearing individual, I’m not particularily bias to CNW or OBs, I just think it a good idea to question accusations of inferior care that appear to be based on strawmen and speculation rather than evidence.

            1. WilliamLawrenceUtridge says:

              Whenever reading about midwives, always keep in mind that the US midwives are not necessarily equal to non-US midwives. There’s an enormous difference between a CNM (a nurse) and a direct-entry midwife (someone who took a weekend course).

              It’s a substantial complication in the discussion and literature, one that should be kept in mind.

  26. winmaxe says:

    I like reading the SBM website and receive valuable information from it. I appreciate the article about Advance Practice Nurses( APN). There are some differences in the education between a APN and a Physician Assistant. I will only mention one general difference. The PA education is tailored to be primary care whereas a nurse practitioner or APN specializes. As far as I know many PA do end up in specialist professions such as emergency, hospital and orthopedics. There have been some programs ( Universities and Hospitals) that are tailored to formally educate PA in a residence program, but there are not many. My impression is that the trend will essentially not change much. PAs will continue to receive a general education with additional residencies as an option. Currently PA have to re certify every six years. Te PA profession is not pushing to be independent as far as I Know.
    The reason that I mention this is that I have been a PA for some time and worked with MDs, PAs and advance practice nurses. It has been said before there are some good one and some not so good, like in any profession.
    One of my points are that medical knowledge is learn-able and yes initial education counts but also subsequent medical education is very important. Things that were taught in med school 30 years ago may not be relevant today. Within a certain scope of practice a PA or NP who is education herself constantly is no different than a MD who does the same.
    How would one compare a MD who practices homeopathy or other woo with a PA or NP who educates herself in science based medicine and applies the current standard of care?
    My last point, some of the qualities mentioned her such as critical decision making, interpersonal skills and practical skills (such as surgical skills) are all teachable and learn-able skills. Why should NPs and PAs be restricted then?

    1. weing says:

      “My last point, some of the qualities mentioned her such as critical decision making, interpersonal skills and practical skills (such as surgical skills) are all teachable and learn-able skills. Why should NPs and PAs be restricted then?”

      Medicine is teachable. If you’re willing to learn you can do it. Just put your nose to the grindstone and do your time. Are you saying NPs and PAs have found a short-cut?

      1. winmaxe says:

        No, I am thinking more along the possibility that, for example PAs, are able to receive their MD degree through a 2nd way so not to go through 4 years of med school. By en-large PAs have had received a fair amount of medical training already. A example already exists in Germany were people who, for example, studied to become a auto mechanic are able to go on and become mechanical engineers. They will receive a diploma and meet all the qualifications in their respected fields.

  27. james ainoris says:

    No doubt Lpn s and RNs deserve more credit for all they do…….they saved my life. However I would only want someone who went to Medical school and passed medcaps in US Canada or EU practicing medicine on me or my family….same as an engineer or scientist obtaining a scientific degree to design aircraft or a bridge etc. Shalom jim ainoris

    1. winmaxe says:

      I am all for meeting competencies, but NPs or PAs are not allowed to attend seminars that teach specific skills such as, for example, ultrasound guided injections.
      I am in favor of a system that would allow NPs and PAs to be trained and tested for specific sets of skills.

  28. CW says:

    I find it interesting, actually quite entertaining, that those physicians in the videos are all either quite aged or a female DO (enough said). With over 30 years as a nurse, 16 of those as a Family Nurse Practitioner, most of my nursing experience was in ER/critical care and advanced practice in ER and family medicine. I come from the era of the ending of the glass IV fluid bottles and relinquishing your chair for “the doctor” I assure you that in mentoring and teaching both NP and Medical students-they perform and ask questions extremely similarly. I have encountered both physicians and APRNs that I would not allow to take care of my worst enemy and I make that statement as a provider who bills for services who has never been sued, zero litigation. As the aged and insecure retire and fade out of practice, I believe the data will prevail.

  29. Randall Sexton says:

    I laugh at the thought of anyone having the nads to name their website “science-based medicine.”

    Dr. John Ioannidis – world’s foremost expert on credibility of medical research
    • 90% of published medical information that we rely on is false
    • 80% of non-randomized (most common) studies turn out to be wrong
    • 25% of gold-standard randomized trials are wrong
    • 10% of platinum-standard trials are wrong

    “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.” – Dr. Marcia Angell

    Sorry some of you spent so much time and money studying what might have been the wrong “stuff.” Knock yourself out finding more info like the above.

    I never did Therapeutic Touch but I believe there have been numerous studies since the JAMA debacle. The JAMA Therapeutic Touch article later became an embarrassment to JAMA and the editor was let go, not only for having a leading medical journal publish such a study but for other leadership issues as well. No self-respecting journal would let a 9 yr old girl, her biased mom (a member of the National Council Against Health Fraud) Stephen Barrett, a retired psychiatrist with a checkered history and member of Quackwatch, and Sarner, (who I can’t remember what he was famous for) be published. Actually, I’m told the JAMA article actually had nothing to do with Therapeutic Touch. (Please do your own research on the above and don’t bother me with it.)

    Dr. Gordon Oakley, research psychologist, says it’s impossible to apply our current scientific research methodology to some other cultures. The Western world has its intellectual knowledge to represent reality but that’s not the only game in town. He studied the Q’ero Indians in Peru and realized his research was not valid because their reality was non-intellectual, for the most part. This might also stand true for much of CAM research, although I don’t care if it’s researched or not.

    I spent 37 years in nursing before earning my Psychiatric Nurse Practitioner title. Just try to imagine the experience I’ve had in that many years and what I’ve seen. Evidence based medicine was pushed in my NP school even though I would bring up points such as “well if it works why is this Vietnam veteran still not finding any relief after 40 years?”

    Unlike those who just spout off opinions about CAM, I actually went and experienced it as well as studied it. That included philosophy of Chinese medicine, the Japanese style of Zen Shiatsu, Reiki, Qigong, and studied shamanism with a medical anthropologist and psychologist as well as with Q’ero Indians in Peru and Shipibo shamans in the Amazon. I’ve also lived in Asia and been all over the world. Also earned two black belts in Korean styles and continue to study Chinese styles. Many of the people studying with me have been physicians, psychologists, and other health professions. When I first started I asked one psychiatrist why he was there. His answer was, “so I can finally start helping people.” One psychologist exclaimed, “I’ll never do talk therapy again.”

    My bilateral tennis and golfers elbow was completely cured after two sessions of acupuncture. I wasn’t expecting much as I was in an Oriental medicine school and students were needling me all the time for practice. However, the student who worked on me this time was already a family-trained acupuncturist who was going to school in the US in order to get certification. I was really happy as my orthopedic surgeon had told me surgery was the only option she had left and she wasn’t too thrilled about the potential results.

    A local veterinarian also used acupuncture to cure a skin rash on our Corgi. I asked him how he was going to keep the needles in with the dog moving around visiting all the other dogs. He told me he was going to put our Corgi to sleep, inserted a few needles, and we watched as he lay down and went to sleep. The vet then inserted a few other needles. After about 15 minutes our dog woke up. Placebo perhaps?
    My wife has natural energy and loves animals. She has healed a lot of critters to the astonishment of their owners. She also works on me a lot. (If you saw my neck and back MRI you might be surprised I’m still moving). Her hands get so hot I can hardly stand it sometimes. I brought her to my Qigong class one summer and several felt pain relief for the first time since their injuries.

    I currently work with Soldiers in an Infantry division. I also teach medical Qigong to Soldiers in a program designed for those who have found no relief within the current medical establishment. My class is the most popular one in the program. In the first session I have them touching, or almost touching, each other to fill the energy exchange. Most succeed in just a few minutes. Tell them it didn’t happen.

    All the above is one long anecdote. As such it is more valuable than any research to me. It is lived, and is one reason I listen to my patient’s stories. So, please don’t bother me with what you think works or doesn’t work as I’m not interested in your non-learned opinion.

    1. weing says:

      “The Western world has its intellectual knowledge to represent reality but that’s not the only game in town.”
      So this is transmitted telepathically to our computer screens? You also used a magic carpet to get to the various countries you mentioned? Not Google Earth, like me? If Ioannidis is correct, what sets him apart from the other studies? If scientific research has such a small chance of being correct, what is the chance of non-scientific research, such as yours being correct? Snow-ball in hell?

    2. windriven says:

      @Randall Sexton

      I congratulate you! In 60 years of pumping air on this planet I have never read such a willful misinterpretation of other people’s words.

      You have totally missed the point. It is the self-reflective and critical nature of science that gives it its power. It is why airplanes routinely fly faster than the speed of sound. It is why you can sit at your keyboard and share your puerile musings with the world. It is why kidney transplants have become all but routine.

      But anecdote and superstition are so much easier. Confirmation bias proves all. Failings are quickly forgotten or written off to lack of faith or treatment too late.

      I’m sorry – no, I’m disgusted that you have managed to get a license as a nurse practitioner. You will feel emboldened and entitled to spread you delusions. Worse, your licensure will encourage others to give it undeserved credence. Your patients have my deep sympathy.

      1. Randall Sexton says:

        No, I didn’t miss the point about the “power” of science. Knew that long ago. However, unlike many others, science is not the only “Bible” out there which simply means I have more tools in my tool box to give patients what others may not be able to give them.

        Please don’t be disgusted until you talk with my patients and get them to tell you why they switched from your care to mine.

        What’s your next point?

        1. WilliamLawrenceUtridge says:

          That science is imperfect but self-correcting once employed, primarily due to its emphasis on iterative testing and reference to data that allows refinement over the course of years to determine what portions of an intervention are vital, and which parts are irrelevant. For instance – practitioner enthusiasm is important in acupuncture. Needling location is not. Actual needling is not.

          The other tools you have appear to be solely “in my experience” anecdotes, the kind that led doctors in centuries past to believe that bloodletting “in their experience”, healed patients.

          I could find anecdotes that John Edwards can talk to the dead. I can find anecdotes that the CIA beams thoughts directly into the heads of random homeless people. Would you find these anecdotes convincing? Because that guy on the corner shouting at pigeons? He’s absolutely certain, unshakeably so, that Barak Obama is vitally concerned with his daily bowel movements. I can find anecdotes of a woman who is convinced the entire constellation of Draconis disappeared, and nobody noticed but her.

          To clarify – my point is that anecdotes are unconvincing.

          1. Randall Sexton says:

            They are useful when the patient no longer has the complaint, correct?

            1. MadisonMD says:

              Randall, just how far do you intend to go with your Post hoc ergo propter hoc? This will not meet a graceful reception at SBM.

              Please, educate yourself.

            2. WilliamLawrenceUtridge says:

              Um, no, they aren’t. All you can say is that person is telling you that their complaint has gone away. You don’t know if they’re going to a different doctor in disgust. You don’t know if they’re lying to you. You don’t know if they’re committing suicide after they leave your office.

              And mostly – you’re apparently dealing with purely intrapsychic complaints. Mental anguish is qualitatively different from physical hardship. This makes research more difficult, not impossible. And in my mind, it still makes lying to patients and reinforcing delusions about the source of their problems unethical.

    3. mousethatroared says:

      Randall Sexton “I currently work with Soldiers in an Infantry division. I also teach medical Qigong to Soldiers in a program designed for those who have found no relief within the current medical establishment. My class is the most popular one in the program. In the first session I have them touching, or almost touching, each other to fill the energy exchange. Most succeed in just a few minutes. Tell them it didn’t happen.”

      Forgive me for the long post but it takes a bit to explain.

      Actually there could be an explanation for this that isn’t related to scientifically undetectable energy exchange.

      Many of these soldier may experience severe to mild stress/anxiety related symptoms. There is a good chance they are perpetually alert about their personal space, many may maintain a reasonable distance from others and are not huggy, hands on types.

      Exposure and Response Therapy is a cognitive therapy that can be helpful with anxiety disorders (and PTSD as well). It uses the gradual exposure to anxiety provoking stimuli to allow the stress response to adapt to the stimuli…thus lowering anxiety symptoms eventually. So, for a person for whom invasion of personal space provokes an uncomfortable emotional sensation (whether is it anxiety or discomfort at defying social norms) repeat mild exposure to that stimuli may help relieve some symptoms.

      I hope my explanation makes sense. I’m not a psychologist or therapist. Personally, I have social anxiety. I uncomfortable being physically close to strangers (except in big crowds, strangely enough). So my inclination is to avoid walking down a shopping aisle that has several people in it. For a while I was unthinkingly walking around several aisles to get to the food I needed, not because I was really anxious, just because it just seemed more comfortable. Then I decided, “wow, this is a time waster and not particularly healthy” So I started forcing myself to walk down any aisle that I could get the cart down. Now I force myself to walk down an aisle where I have to say “excuse me” to get someone to move their cart.

      The point is – these little steps can feel really exhilarating in a way that it may be hard for someone not in that situation to understand. When I first started doing this, I felt like the king of the world. Strange, but true. It’s very possible that your soldier could be experiencing a similar emotion. Something to think about, maybe.

      The big step are much harder, not so fun. ;)

    4. David Gorski says:

      I currently work with Soldiers in an Infantry division. I also teach medical Qigong to Soldiers in a program designed for those who have found no relief within the current medical establishment.

      You aren’t helping the NP cause. Here I just wrote a long, detailed article on why NPs should be allowed to practice to the full scope of their training, and you come in, a psychiatric NP, and brag about how you believe in quackery like acupuncture and use “energy healing” like Qigong. Seriously, dude. You aren’t helping. I can picture NPs who practice science- and evidence-based medicine reading this post, being happy that I support them, and then cringing when they get to your comments.

      1. Randall Sexton says:

        David, I’m 63 yrs old today and have been in health care 43 yrs. I’m past the bragging stage, but I’m not past the “getting in your face, you bring your checkbook, and let me show you something stage.” I care about people which is why I expanded my knowledge base. I believe in what I believe because it works. Did you not read my comments above? Acupuncture cured my elbows in two sessions after a year of misery and my ortho doc having no option but surgery. I’ve helped people who have not been helped in the medical establishment. My activity level is hard to believe if you looked at my neck and back MRI. My wife had FMS and went on to earn a 3 rd Black Belt in Hapkido with Zen shiatsu sessions and other energy work. Like I mentioned in NP school with my instructors who were as dense as you, “if EBM works then why is this Vietnam veteran still sick after 40 years.” Come on, man you really need to get over your issues and ego, and experience, not just believe there’s more than what you know. Why don’t you go back and tell all my patients that they are still sick? That should go over well.

        1. MadisonMD says:

          I believe in what I believe because it works. Did you not read my comments above? Acupuncture cured my elbows in two sessions after a year of misery and my ortho doc having no option but surgery.

          Randall– there you go again. You ascribe causality when none can be inferred from your data. You think us fools enough to believe that your anecdotes are unbiased and representative samples of your personal and professional experiences over the past 4+ decades. Open your mind and admit you could be mistaken.

          1. Randall Sexton says:

            But nothing matters except I’m pain free andnever had a problem btw. Doesn’t matter what the causality is but I’m giving credit to the intervention that was actually occurring when the pain went away. Otherwise, it might have been the mice that ran across my back yard the previous day. Sure I could be mistaken but about what. Do we have to argue that a chair is not a chair?

            1. Harriet Hall says:

              A chair is a chair, and post hoc ergo propter hoc is a logical fallacy.

            2. WilliamLawrenceUtridge says:

              Randall, how do you explain the fact that if you take two groups of patients and manipulate the factors of acupuncture (needling location, needling depth, not needling, practitioner enthusiasm) that both groups of patients improve the same amount, except for the ones who got practitioners who didn’t gush about how great acupuncture is?

              The body does heal itself, even after years. Pain fades, joints limber, and ranges of motions extend as a matter of course.

            3. MadisonMD says:

              Doesn’t matter what the causality is but I’m giving credit to the intervention that was actually occurring when the pain went away.

              Wrong. It does matter. If the intervention did not actually remove the pain then it will not do anything for someone elses pain. If the intervention actually did remove the pain then it is likely to to help others. It is crucial to know the difference because, as a clinician, your job is to help the next patient, not to congratulate yourself for “curing” the last one.

              You are practicing shamanism. You can crawl out of your hut, shake a few bones, feathers, at your patient and claim that this made them better. Humans did such things for eons. However, health and life expectancy did not improve until causality could be inferred. Knowledge of causality allows a clinician to apply effective treatments and avoid that which is ineffective.

            4. Jeffrey says:

              Just to make sure everyone knows, this kind of thinking is not endorsed in nursing schools. The hierarchy of evidence that I’m sure most of us learned in school does not even include antecdotal evidence. In fact expert opinion barely makes the cut.

              This link is not from where I went to school, but the content is the same.
              http://researchguides.ebling.library.wisc.edu/content.php?pid=325126&sid=2940230

        2. Andrey Pavlov says:

          We don’t doubt that at least some of your patients got better. What we doubt is why they got better. And we have no reason to believe your idea of why they got better and plenty of reason to believe it certainly wasn’t the case. So we don’t need to tell your patients anything. We just need to tell you to stop being so gullible. As Feynman said, the first thing is you must not fool yourself… and you are the easiest person to fool.

    5. WilliamLawrenceUtridge says:

      I never did Therapeutic Touch but I believe there have been numerous studies since the JAMA debacle.

      So…can you provide any well-controlled studies that demonstrate it actually makes a difference? It’s funny that you fetishize Ioannidis, but your answer seems to be “unsourced assertions” as if they were somehow superior.

      Dr. Gordon Oakley, research psychologist, says it’s impossible to apply our current scientific research methodology to some other cultures

      Why? A dead person is a dead person, hard outcomes would seem to be the same the world over. Bactieral infections either get better, or don’t. Vaccines either work, or don’t (they do, which is why polio is almost eradicated and smallpox is).

      My bilateral tennis and golfers elbow was completely cured after two sessions of acupuncture.

      How do you know it was acupuncture that did it? Wounds and overuse injuries do heal on their own.

      All the above is one long anecdote.

      Yup.

      As such it is more valuable than any research to me.

      Yes, that’s probably true. Of course it’s only valuable to you, because even if acupuncture works for you, the evidence base for it reveals that it doesn’t work for anyone else. Practitioner enthusiasm is far, far more important than needling location or even whether you penetrate the skin – and if it doesn’t matter where you put the needles, and doesn’t matter whether they actually break the skin, is acupuncture even a thing?

      It is lived, and is one reason I listen to my patient’s stories. So, please don’t bother me with what you think works or doesn’t work as I’m not interested in your non-learned opinion.

      Don’t worry, we’re not interested in yours either. We recognize that one person’s experience is an unreliable guide to medical practice, as is their certainty in their conclusions.

      Please, feel free to read another, any other website, and feel no obligation to post a comment ever again. Your opinions are not really helpful here.

      I’m always amused that people cite Ioannidis to prove their favourite form of quackery “works”, when Ioannidis’ conclusion is that we should trust postitive results less, not that negative results are actually wrong.

      1. Randall Sexton says:

        “So…can you provide any well-controlled studies that demonstrate it actually makes a difference? It’s funny that you fetishize Ioannidis, but your answer seems to be “unsourced assertions” as if they were somehow superior.”

        Get your assistant to look them up as I’m too busy and really don’t care about TT. I don’t idolize Ioannidis or even the BMJs or recent editor of NJEM (wasn’t it) who says much of current research is false. Doesn’t mean the scientific method is false, just the product. It’s done by humans and they can never be blinded enough. Sure, I’m reading research in my field almost daily but I don’t view it as blind faith.

        “How do you know it was acupuncture that did it? Wounds and overuse injuries do heal on their own.”

        Sure they do and I had suffered for a year. Excuse me but the pain in one elbow went away completely in one elbow and partly in the other, and completely after two sessions, while I was being needled. Why not 2 months earlier?

        “Yes, that’s probably true. Of course it’s only valuable to you, because even if acupuncture works for you, the evidence base for it reveals that it doesn’t work for anyone else. Practitioner enthusiasm is far, far more important than needling location or even whether you penetrate the skin – and if it doesn’t matter where you put the needles, and doesn’t matter whether they actually break the skin, is acupuncture even a thing?”

        So that’s why millions of people keep getting something that doesn’t work. I guess it also works with animals due to the placebo effect. We’ve had sham knee surgery also which was as effective as the real thing. Perhaps we need to focus more on the placebo effect?

        “Don’t worry, we’re not interested in yours either. We recognize that one person’s experience is an unreliable guide to medical practice, as is their certainty in their conclusions.”

        No, one person’s experience is all there is. Each patient has their own experience, their “story.” That story is what I listen closely too, and I try to understand their story. I can understand their past as they are living it now. By doing this you truly understand unless you’re like the ego-driven cardiologist and neurologist a patient saw recently, and told me about today. He’ll never return to both.

  30. Zoe237 says:

    Bravo Dr. Gorski! I hope you have written a letter to support your wife and the thousands of other NPs who deliver fantastic care.

  31. PMoran says:

    @Randall Sexton, —

    Other than fatuous (?) statements like “– their reality was non-intellectual — ” — there is nothing you have stated that is not consistent with present “Western” scientific understanding, including exactly why practitioners of CAM, folk medicine, and other complex interventions (like yourself) can come to have such utter faith in the effectiveness of their activities.

    That includes being able to concede some benefit from them, especially with subjective, psychological and psychosomatic complaints. There are however, other powerful illusions within daily medical practice that practitioners are almost never fully conscious of.

    This is why we have had to relinquish some of our decision-making to quite complicated clinical studies. We are still looking for reliable ways of keeping bias and other illusions out of those. We are still not quite sure what some kinds of study mean in terms patient benefits (in my view). Nevertheless Ionnadis and Angell are being listened to.

    medical science is not only to do with certain understandings as to how the human body works in health and in disease, it involves les

    1. Randall Sexton says:

      “…why practitioners of CAM, folk medicine, and other complex interventions (like yourself) can come to have such utter faith in the effectiveness of their activities.”

      I don’t have “utter faith” in CAM any more than I do Western medicine. I believe in both. Faith or belief is one thing one. One might for example believe in the Bible but I don’t care if you believe in CAM or not as you can become a believer when you feel it or see the difference. You think I’d be offering this if it never worked with patients?

      So what do you do when you have a Soldier who has visual and tactile hallucinations of an old man and a young girl he killed in Afghanistan? The girl was killed accidentally when the Soldier returned fire. What all do you have in your toolbox to address his suffering?

      1. WilliamLawrenceUtridge says:

        You think I’d be offering this if it never worked with patients?

        Oh yes, very much so. The history of science and medicine is filled with people who offered things to patients, even though they did not work. Bloodletting is always the example that springs to mind, but prayers to Thoth is another one, the ritual sacrifice of chickens a third, and sprinkling baby powder on patients undergoing open heart surgery is a third.

        So what do you do when you have a Soldier who has visual and tactile hallucinations of an old man and a young girl he killed in Afghanistan? The girl was killed accidentally when the Soldier returned fire. What all do you have in your toolbox to address his suffering?

        Enormous difference between mental health and physical health. Claiming acupuncture works as a specific intervention rather than as a nonspecific desensitization – also an enormous difference.

        Merely because scientifically-validated medicine doesn’t have anything to offer doesn’t automatically mean your offering is effective. That’s a false dilemma. It also doesn’t mean yours “works” because of the needle.

  32. mousethatroared says:

    ” When I first started I asked one psychiatrist why he was there. His answer was, “so I can finally start helping people.” One psychologist exclaimed, “I’ll never do talk therapy again.”

    This is very strange. I know many people who have been helped by psychiatrists and psychologists and I myself have been helped. Clearly a psychiatrist or psychologist can’t help every patient, but I have to ask myself what were they doing wrong in their previous profession that they’re success rate was so low? The fact that they and your are discarding tools that are proven to be successful in some cases is disconcerting. If you said, I think these things work, but I like to add these other methods…I wouldn’t agree, but I would sympathize. It like this.

    If you say, “Well, this hammer didn’t work for me” the normal question would be, “Well, are you using it right?”

    If you say “This hammer isn’t good for drilling a hole through wood.” It’s reasonable to want another tool.

    But, it’s doesn’t make sense to throw out your hammer because it doesn’t work for all carpentry.”

    As a homeowner, I’d be very uncomfortable with a carpenter who has completely discarded the concept of hammers and derides other carpenters who advocate for the use of hammers in carpentry.

    1. Randall Sexton says:

      We are all taught tools that work in some cases, not in others. The more tools you have the better chance you have of helping someone, especially if many tools have not been successful. So don’t worry about me throwing away all the tools. I can give you Zyprexa if appropriate or perform a fire ceremony is that’s what’s needed.

      I’m aware that Paxil and Zoloft are the only two drugs approved for PTSD, yet in clinical practice for most or my patients they just don’t work or have intolerable side effects. Venlafaxine, from clinical experience, tends to work better in many cases. In my practice setting, I can’t do a full blown shamanic session for example, but I can use my skills in tracking what’s going on with them even if there is a paucity of speech.

      I didn’t say anything about anyone’s success rate. Much of what we do in behavioral health such as meds, therapy, etc., equal a placebo affect (same has been shown with surgery). What the people I mentioned above found out was that they can now accomplish in 1-2 sessions what normally took years. Much of the new success was from rituals and ceremonies, vs talking for many years. Many of these people have had their scientific world-view turned upside down. I did 4 grand rounds presentations last year and 1 this year to over 50 people in our department. Do you think there is a reason they didn’t run me off after the first one?

      As an aside much of our current psychotherapy didn’t originate with Freud but tens of thousands of years earlier. I can show the similarities between current practice and that of indigenous cultures.

      A few examples if you like; less than 30 minutes to help a guy realize he felt “alienated” all his life but never quite could put a handle on what it was. I did a soul retrieval on him and saw alien spacecraft doing touch and go landings on a runway in a forest. Unknown to me he was a pilot and initially thought it had something to do with his own private plane which he had recently sold. He broke down sobbing a few minutes later when it hit him.

      How about the lady with 20 plus years of nightmares treated in one session, never to have her nightmares return. Or the lady who was phobic about water, including taking a shower. Couple weeks later she was in the pool up to her neck. I could go on and on.

      It’s really not that “weird.” It’s just another language that you can be taught.

      1. mousethatroared says:

        “I didn’t say anything about anyone’s success rate.”

        Well it did sound like you did, “finally start helping people” can easily be read, haven’t helped people yet. To say you’ll never do something again, sounds like it was a pretty profound failure.. But it’s good to know that you are not discarding your other tools.

        It’s great that you feel you’ve had success with your treatments. But if the treatment, rituals are as helpful as they appear, there’s no reason they shouldn’t be observable with the scientific method.

        How do you know there isn’t an unforeseen side effect? For instance I have heard of others who are cured of a phobia by a dramatic treatment, only to be incapacitated by another phobia or acquire a substance abuse problem, when they had difficulty with new anxiety symptoms that crept back that they were unprepared to recognize or deal with. Kinda like weight loss, dramatic changes are not always the best route. You don’t really know unless you can observe it and find predictable outcomes and side effect to watch out for. That is what science is about. It’s not about aquiring some grandiose certificate of westernization. It’s about being curious and continually trying to improve results.

        Maybe this is one reason I respect and admire this approach “My confidence … lies in my basic belief that as in science so in Buddhism, understanding the nature of reality is pursued by means of critical investigation: if scientific analysis were conclusively to demonstrate certain claims in Buddhism to be false, then we must accept the findings of science and abandon those claims.”

        ~ Dalai Lama XIV

      2. WilliamLawrenceUtridge says:

        We are all taught tools that work in some cases, not in others.

        What about a tool that doesn’t work for anybody? You’re arguing some heavy postmodernism here, but postmodernism doesn’t make the body go away, or basic physiology change. The reality is – we know that acupuncture is good at alleviating symptoms, for some people, in certain conditions. The factor that matters most is how confident and charismatic the practitioner is, followed closely by how long the patient can talk about their symptoms. The factors that matter least are needling location, and whether you needle at all (only important – if the customer thinks you are needling). What does that say about acupuncture? Incidentally, pain and nausea, the symptoms acupuncture is best at relieving, are the two symptoms most susceptible to placebo effects.

        And if your shaman ceremony only works for someone who gives a crap about shamanism, what does that say about your shaman ceremony?

        I get it – you are more concerned about outcome than process. But that doesn’t change the fact that your process is unreliable, has uncertain transfer across patients, and I kinda doubt if it’s a long-term solution for most people. What do you do when you treat an atheist? Or someone from a tradition that doesn’t have shamans?

        Science is about distilling the essence, until you can identify those factors that matter most and transfer across people. You’re not doing science. You’re unlikely to convince most here, we care about science. Wouldn’t it be better if you were able to distill out of all you do, those factors that matter most, universally, and transfer them as a teachable skill? Thus helping thousands, if not millions of people, rather than the bare dozens you can help one-on-one?

      3. Indigo_Fire says:

        I think this tells me all I need to know about your grasp of reality, or lack thereof.

        1. Indigo_Fire says:

          D’oh! Blockquote fail!

          What I meant to post was the following:

          “…less than 30 minutes to help a guy realize he felt “alienated” all his life but never quite could put a handle on what it was. I did a soul retrieval on him and saw alien spacecraft doing touch and go landings on a runway in a forest.”

          I think this tells me all I need to know about your grasp of reality, or lack thereof.

          1. MadisonMD says:

            When I first looked at Randall’s post, I thought to fabricate a ridiculous anecdote to illustrate the worthlessness of his.

            When I got to the part about alien spacecraft, I realized that the exercise was both futile and needless.

          2. Randall Sexton says:

            And you question it because it worked? Now I question your grasp of reality and compassion for fellow humans.

            1. MadisonMD says:

              Dang. More post hoc ergo propter hoc! My son learned about placebo controls in 6th grade. You still don’t understand? Do you wish to be educated?

            2. Andrey Pavlov says:

              No, we question how you know it worked. If I told you that I could cure your asthma by kicking you in a specific way in the rear, would you believe me? Why not? What might you ask in order for me to prove it? Or would you just pay me $50 to kick you in the buttocks?

              We are asking you to prove it and what we are saying is that what you are providing is not proof. It is many things, but proof that it works is not one of them.

              1. Randall Sexton says:

                If I had asthma and nothing was helping it, I’d certainly want you to kick me in the butt. If it worked, I’d be a happy camper, wouldn’t I? If it didn’t work I’d never come back and see you nor would I refer patients to you. That would be the proof you are seeking, or success is the only proof I need. Or do you need a double blind study to calm you down? To me, with my asthma gone, I wouldn’t give a rat’s ass.Proof that it works comes form the patients and should be the easiest thing for you to understand. Maybe your kid can help you with that.

              2. weing says:

                “If it worked, I’d be a happy camper, wouldn’t I? If it didn’t work I’d never come back and see you nor would I refer patients to you.”

                What about, it seemed to work, you went home and died of the asthma? Who would you complain to? The quack is happy because no one complains that the treatments don’t work. That is the more likely scenario.

              3. Andrey Pavlov says:

                OK, then please Randall I can assure you that a swift kick in the ass will cure you of any ailment that you have. Please come see me in my office for every single imagineable problem you have, pay me $50 each time, and I will render some “therapeutic touch” your way. After you sign appropriate release of liability forms, of course.

              4. MadisonMD says:

                Awesome, Andrey. But you need to sell him on your panacea (shall I say “pantsacea”– sorry bad one) with a few anecdotes.

              5. Andrey Pavlov says:

                Madison, I’ll make a blog with before and after photos. The after photos will have lots of people smiling with a big thumbs up. I can’t wait to pay off my loans by kicking people like Randall in the ass.

              6. mousethatroared says:

                weing “What about, it seemed to work, you went home and died of the asthma?”

                Oh weing, Living and dead are such reductionist terms.

      4. Sawyer says:

        Have you really thought about the long term consequences of this approach? This is one of the few criticisms of modern medical techniques that I think holds any water, so I think it’s fair to apply it to alternative techniques as well.

        What happens when people with serious mental health problems find out they’ve been paying for placebos? Some of them will shrug their shoulders and say “oh well, it worked for me”, but what about the people it didn’t work for? I would already be in a foul mood if I was a veteran and was given an ineffective drug to deal with PTSD, but I would outright lose it if I was told I needed to be more open-minded and see a reiki master instead. And what about the next generation of medical researchers that dump thousands of hours and dollars into learning this stuff and doing research on it only to find out there’s nothing magical about it? You may be well aware that these techniques are “just a tool”, but after years of dealing with CAM fans we’ve found most of them have a far less pragmatic approach to their practice. What happens when healthcare providers stop covering real treatments in favor of your alternatives to keep costs down? How big is this house of cards going to get?

        If you are truly able to employ alternative therapies with a moderate success rate and without losing your grasp on reality, congrats. You are almost certainly an outlier. How are other practitioners going to adopt your standards in the future? The past 150 years of medicine has shown they like to set the bar as low as possible.

        1. Sawyer says:

          Whoops, ignore my comment about being “pragmatic”. I somehow missed that alien story Indigo pointed out.

          1. mousethatroared says:

            Yeah, I kinda missed that bit too, initially.

            1. Randall Sexton says:

              Didn’t miss the part about it working though did you, lol? Now, tell me what EBM techniques you’d use and how long it would take to work. Come on….

              1. MadisonMD says:

                Post hoc ergo propter hoc again…. Wow, just wow Randall. Willful ignorance.

              2. mousethatroared says:

                Actually, It looks like you missed the part where I said I’m not a psychologist or therapist. You also missed answering my questions up thread. They are the kind of questions that I (as a patient) might ask any mental health professional about their proposed treatment. You have no answers, only patronizing assurances.

                Personally, what I use for my symptoms presently is a combination of Brain Lock (Jeffrey M. Schwartz) techniques, Mindfulness and ERP, with a dash of thought correction as well as trying to get some exercise each day. My understanding is that this approach is reasonably evidence based.

                How long, huh. Well, I think overall I’ve done maybe 20 – 30 cognitive therapy sessions in 3 sets of 6 to 10 sessions at different point in the last 17 years. Maybe 5 ish psychiatrist visits (piggy backed on the therapy sessions) when I was taking medication for about a year. I also have read a reasonable amount, books that were recommended by my therapist and books that focused on the above techniques.

                But the work is ongoing, much like the work of maintaining a healthy body is ongoing. I’m just happy that I have developed a skill set that helps me analyze my ups and downs and adjust my approach accordingly. I doubt that being “healed” by a spiritualist would result in that kind of skill set.

            2. mousethatroared says:

              Actually I have an alien story….

              Otherwise entitled Fun with Hypnopompic Hallucinations. Certainly didn’t offer ME any spiritual epiphanies.

      5. David Gorski says:

        What the people I mentioned above found out was that they can now accomplish in 1-2 sessions what normally took years. Much of the new success was from rituals and ceremonies, vs talking for many years. Many of these people have had their scientific world-view turned upside down. I did 4 grand rounds presentations last year and 1 this year to over 50 people in our department.

        Evidence, please? I see lots of assertions, but no valid scientific evidence.

        Again, you are not helping the cause of APRNs by writing such things in the comments of this post.

        1. Randall Sexton says:

          Evidence will be when you run out of options with a patient and can think of nothing else to do with a reductionist approach. Then I’ll open my bigger toolbox and see if I can help. I may be successful or maybe not but I have more options than you . Plus I can be of benefit when the power goes out and you have no access to diagnostic tools.

          The reason you see so much CAM and you probably know the stats on the number of people using it, is because you are failing at your job. People wouldn’t be looking elsewhere if you had helped them. Last time I looked the US was #37 in healthcare in the world. You sir, are part of that problem.

          I’m perfectly happy with anyone that wants to have a strict science-based approach. That’s fine as long as you consider half of it might be wrong and I hope you are studying the right half. You don’t insult me at all with your comments as I merely went and availed myself of exoerience and knowledge that you don’t have. I did that because I saw how ineffective Western med could be in some cases.

          1. Harriet Hall says:

            “People wouldn’t be looking elsewhere if you had helped them”
            Demonstrably false. When asked “Why did you use CAM?” only 28% of people said it was because they believed conventional medicine couldn’t help them. 50% said it was because they thought it would be interesting to try. http://www.cdc.gov/nchs/data/ad/ad343.pdf

            “I merely went and availed myself of exoerience and knowledge that you don’t have”
            In other words, you disregarded everything we have learned about science and about the psychology of how people come to believe ineffective treatments work, and you deluded yourself into believing that your belief system constituted “knowledge.”

          2. Sawyer says:

            Forget about the medical aspect for a moment and think about big picture. Who are the people you are offering your services to? Might these people be tasked with making important decisions about our national defense 20 years down the road? Can you think of some negative consequences of having them buy into mystical ideas about science and medicine?

            There is a reason why many of us take such a hard line with alternative medicine and the military, and it’s not just because taxpayers are funding it. Google James McCormick. Look at the terrible cost we had to pay because of that despicable asshole and the people that believed in him. How are our future military leaders going to prevent people like that from gaining traction when soldiers are getting therapy that specifically discourages them from being skeptical and scientifically literate?

            Sorry for being a heartless bastard, but promoting reason and scientific literacy in the military is an absolute necessity. If it makes physical or mental therapy tougher, so be it.

            (For the record I don’t accept that your approach helps anyone short-term either)

          3. Andrey Pavlov says:

            You realize that your argument amounts to “when everything we actually do know fails, I’m going to throw whatever made up shit I can at the wall and hope it sticks.” Your “toolbox” is bigger because it doesn’t actually contain tools – just whatever crap you can make up because it sounds good.

            Sadly, not only is that a waste of time, money and resources, but is actually likely to harm some people along the way.

      6. MadisonMD says:

        I did 4 grand rounds presentations last year and 1 this year to over 50 people in our department.

        Might I suggest that you request critical feedback from those that walked out early?

        1. Andrey Pavlov says:

          That, Madison, is an excellent point about where we fail. Nobody in our profession wants to be “mean” particularly at grand rounds. It is much, much more common to just walk out and say it was a crap presentation over coffee with a friend than to be so “mean” as to call someone out for a scientifically unsound presentation. I think a big part of it is that we do find confrontation difficult, but also that when you know it is crap but don’t know why it is crap it is much harder to actually do anything about it. Have someone who loves CAM up on stage and all you can say is “that is BS!” and the likely response is a Gish Gallop of sorts since CAM folk are notoriously much better at rhetoric than science and if you don’t have a really good understanding of why it is crap, you’re sunk. And then you look like the a-hole. We aren’t trained to do PR or rhetoric and one must study the rhetoric of shysters to really combat it effectively. Which is why – despite the fact that I love him and it saddens me to say this – Bill Nye is going to get his ass handed to him.

          1. David Gorski says:

            Yeah, I fear the same thing. It is likely that Bill Nye will appear to lose big-time, unless he takes this seriously and really learns the many creationist tropes that he will face and why they are tropes.

            1. Andrey Pavlov says:

              Honestly, I love Bill Nye. I think he is an awesome guy. But besides being naive about it (have you seen the videos of him discussing it? he seems to think that folks like Ham just haven’t been exposed to good science and once they are they’ll accept the folly of their ways) he is just honestly a pretty terrible public speaker. I’ve watched many interviews with him and I really dig them because I dig him and science, but from a purely objective standpoint he is profoundly underwhelming. No panache, no charisma. I was impressed with him on dancing with the stars, but he doesn’t bring that to most of the public speaking I’ve seen him do. And even if he did, that isn’t enough to go up against someone like Ham. Besides all that, he is not an evolutionary biologist. In any debate, but particularly a dishonest one, you need to know your topic better than your opponent and know their arguments better than they do. I think his motivation is admirable, but I also think there is a bit of morbid curiosity on his part. Just like how Peter cannot believe that people with such incredibly skewed worldviews that don’t comport with reality can write or even cite scientific papers, and just like my own fiance just can’t believe that other people can actually believe such whackaloon stuff, Bill can’t believe that Ham and his acolytes can have actually looked at the plain facts of the evidence and still proclaim, let alone genuinely believe, the ridiculous things that they do.

              The worst part is that, besides the incidental notoriety and continued imprimatur of “teach the controversy”, this is being held on their turf with all proceeds going to benefit the Creation “Museum” and AiG, with all DVD sales, production, and everything coming out of it controlled by them and profiting them.

              I love the man, but he’s made a mistake here.

              1. WilliamLawrenceUtridge says:

                In any debate, but particularly a dishonest one, you need to know your topic better than your opponent and know their arguments better than they do.

                Heh, no you don’t, not with creationists. The index to creationist claims is more than adequate since creationists never innovate. They just recycle.

              2. WilliamLawrenceUtridge says:

                Anyone in touch with Nye? He might be interested in that list – and also this account of a successful (at least from the perspective of the guy telling the story) debate from Talk.Origins.

                http://www.talkorigins.org/faqs/debate-rob-day.html

              3. Harriet Hall says:

                He described his talking points here: http://scienceblogs.com/gregladen/2014/01/09/debating-evolution-vs-creationism-bullet-points/ Basically, it sounds like he is going to deny that there is anything to debate. This could be interesting. It takes two to fight; what if Bill simply disengages?

              4. windriven says:

                “Besides all that, he is not an evolutionary biologist. In any debate, but particularly a dishonest one, you need to know your topic better than your opponent and know their arguments better than they do”

                Where is Hitchens when we need him. He wasn’t an evolutionary biologist but he was a splendid debater and reveled in ripping the lungs out of creationist types.

                That said, your point is well taken. The winning strategy in the Dover, PA “monkey girl” trial was a parade of evolutionary biologists and molecular biologists who dismantled the ID “experts” arguments with clear, calm, detailed explanations of the real science. That won’t be easy for a mechanical engineer.

              5. Andrey Pavlov says:

                @WLU:

                Yes, I know well that is the case. But I don’t have confidence that Nye does. I could be wrong, but based on the interviews I have seen with him it seems he doesn’t realize that the true “debate” of a creationist is them just repeating the same tired old bullshit over and over again and then running around with their arms in the air like the won. It is, quite literally, cargo cult debating. But in any event, your list does not negate my statement – you need to actually know that list better than they do. And I don’t think Nye does. I’ve never hoped to be proven wrong more though.

                @windriven:

                Oh Hitch. He died whilst I was studying for my first board exam. I remember being profoundly sad that day and I drank a fair bit of Scotch in his honor that night. Perhaps a lost a couple of points on the exam as a result, but it was worth it.

                And yes – he was the prime example of how to debate a creationist. Eviscerate their rhetoric with the fury of a thousand suns and the mercy of Ghengis Khan himself. In that case, you needn’t be an evolutionary biologist to debate Ham, but he knew enough salient facts anyways.

                The Dover case was, in a word, awesome. I hate that I have to point to legal precedent to make a scientific point, but it is very handy ammunition to have. Particularly when you can point out that the judge in this case was himself a believing and practicing Christian so as to handily dismiss that trope. But a structured legal proceeding where there is time and expectation of formal discourse with evidence and experts to explain it is a far cry from sharing a stage with Ham in front of his acolytes. People watching these sorts of things don’t have the know how or capacity to process in real time the actual evidence. Hell, most people don’t, regardless of their background. I remember watching a debate between Hitch and Berlinski* and I could not keep up. Every time after Berlinski spoke I knew he was wrong but I couldn’t fathom a response or reason why. I even paused it a few times to give myself an extra minute or two to think to no avail. Yet Hitch, the glorious bastard that he was, slapped him down each and every time without pause (one might say… without a hitch [sorry, couldn't resist]). The point is that is why a Gish Gallop works. People expect simple answers with the trappings of victory going to the victor. Give a simple answer and pretend like you won and you did.

                @Dr. Hall:

                Sadly, if Nye disengages, he loses as well. Any time a reputable scientist refuses to debate a creationist because there is nothing to debate or because the individual is an atrocious human being (as in the case of Dawkins and Craig) the opponent crows about how they must be afraid to be challenged and declares victory in absentia. The only thing worse, IMO, is to actually go there and then disengage because then it gets spun as having retreated in defeat (as in Krauss and Craig)**

                It can be achieved effectively, but is difficult to pull off for anyone. And, to put it mildly, Nye is no Hitch.

                *If you want to watch a really amazing show of rhetoric, the best by far I have seen is Hitch and Berlinski. Most of the time when a scientist or rationalist/skeptic goes up against a creationist/theistic apologist/whatever it is an unequivocal smackdown of epic proportion (objectively speaking, not popularly as is often the case). That is especially so with Hitch, so unmatched is he in the world of rhetoric. But Berlinski, IMO, gave him the best fight I’ve ever seen him get. Definitely worth the watch.

                ** Yes, I may have watched one or two of these kinds of debates in my day. Harris and Chopra is one of my favorites. I also started liking Dawkins better more recently as he basically seems to have stopped caring what others think of him and flat out calls his opponent a buffoon when they deserve it. But I’ve seen all these – some a few times – which is why I am worried about Nye and the outcome here. And why I agree with pretty much everyone of experience and authority on the matter that it is admirable what he wishes to do, but that he has only the slimmest chance of actually accomplishing it and he is better advised to have just not agreed in the first place.

              6. Andrey Pavlov says:

                Oh, poor Bill. I would totally have a star-struck moment if I met him, but I’m strange that way.

            2. Rules for debating pseudoscientists:

              1 Don’t do it; full stop.

              “A debate is not won by sound argument; it’s [won] by persuasive rhetoric.” -P. Z. Meyers

              Debating pseudoscientists lends the appearance of credibility to their position, and suggests debate is warranted when it is not.

              2 Research and prepare for the tactics of your opponent & their allies. Seriously, it’s unlikely that any previous experience in debating is going to properly prepare you for the onslaught of Gish Gallup, pseudoscience, and logical fallacies you’re going to be subjected to. If you aren’t prepared or don’t have an effective means of dealing with it all, they’re going to make you look bad or even foolish.

              3 Insist on neutral ground. Insist on ticketed admission and the right to distribute 50% of the tickets yourself. (Insist on a balanced audience)

              4 Insist that any revenue from ticket sales be donated to a mutually agreed upon charity. You don’t want to help raise funds for your opponent.

              5 Have the event recorded by a neutral third party that provides copies of the video to both parties.*

              6 Insist on prior agreement with all involved parties (participants, audience members, etc.) regarding publication rights of video by both participating sides.*

              *It is not uncommon in the past with such debates, when the video is recorded by the other side and the debate goes our way, the other side will renege on promises to publish the video or will publish only selected excerpts of the video.

              7 See point #1

              1. windriven says:

                Nice to see you here again Karl.

                Excellent points. Number 7 is my favorite.

              2. MadisonMD says:

                Re: #1 and #7
                If showing a photo of a celestial object >6000 light-years away is insufficient to draw a conclusion, then there is no basis in fact on which to hold a debate at all.

        2. Randall Sexton says:

          No one walked out. Like I said I’ve done 5 this year and if no one liked it there wouldn’t have been #2. This is a dept with 50 plus professionals. Evaluations are also done for each presenter.

          1. Andrey Pavlov says:

            Care to invite a few of us, myself included, to listen to one of your grand rounds? I would love to attend and promise I will be absolutely civil and stick only to dispassionate science.

          2. MadisonMD says:

            Now I’m curious– which department?

            1. Randall Sexton says:

              Behavioral Health…military post.I don’t care who comes.

      7. mousethatroared says:

        I wanted to add that sometimes people over-rate the harm that can be done with psychological treatments, since the illness seldom directly results in physical injury.

        But consider the harm that repressed memory retrival caused. Many people thought the process was true and accurate and was very theraputic. It turned to be untrue. The “memories” were not true and families and lives were destroyed based on false memories and accusations.

        1. mousethatroared says:

          under rate, not over rate…geesh.

  33. Sue Smith says:

    Wow, and maybe if you wanted to practice independently, you should have gone to med school as well. I am so glad no one ever pushed me into the PA field where all I get to do is the mindless tasks the physicians can’t be bothered with.

  34. Angela B. Reed, NP says:

    Thank you, Dr. Gorski. I, and my PNP colleagues, appreciate the fact-based blog. My only concern is that many of the comments suggest that SB2 “expands” NP Scope of Practice. Just as with MD’s, our professional education and training define our scope of practice, with guidelines from our professional groups and state law. SB2 does not “expand” our a Scope of Practice, but aligns our true practice with State law. SB2′s sole purpose is to bring the legislative codes up to actual practice of NP’s, and allows us to practice up to our full scope of practice which is unnecessarily restricted in Michigan and is not consistent with our education and training. Thank you for publishing this and holding MSMS accountable for their fear mongering and promotion of their special interests!

  35. Stephen S. Rodrigues, MD says:

    “I am so glad no one ever pushed me into the PA field where all I get to do is the mindless tasks the physicians can’t be bothered with.”

    This issue has nothing to do with NP ability this has to do with prestige and status … but mostly income.

    A well trained nurse can handle all of the push-button/vending machine everyday medicine.

    Gee actually most push-button medicine and actually be done with a vending machine connected to a computer.

    Now SBM is vital to this simplified mindless practice of medicine. This is the reason all of the non-physician can not begin to comprehend how to solve problems and not do harm.

    The “gotchas” which are 1/10 cases where a pushbutton will actually do harm by wasting time, resources and even kill people. A reasonable mind with the correct tools is vital in these cases!

  36. cathy says:

    I have been a Psychiatric APRN in NH for 15 yrs (& additional 25 yrs as RN). I work in corrections & have the ability to admit, discharge & do out patient MH follow ups. My decisions are accepted by the MD’s I am in practice with & they respect my autonomy. I support my APRN colleagues in Michigan & thank you for writing such an excellent article, doing all the work of researching the literature, as well as supporting your wife.

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