As a patient I want the best of the best diagnosing and managing my medical problems. This article is obviously written by nurses with an agenda. It is much easier to become a nurse than a physician, and the training to become a nurse is much less intensive than that to become a physician. The astute realize that there is a movement to dumb-down medicine so as to pay providers less (an obvious objective of governmental and insurance bureaucrats). Meanwhile the nursing profession is seizing the opportunity to replace physicians at a time when medicine is more complicated than ever. I only hope that in the future I will always have the opportunity to select a physician over a nurse to manage my medical care. Unfortunately the changes I see coming will likely make the physician profession less attractive to the brightest students, who will have better opportunities in other professions. Why spend all those years in training and take on $100,000 to $2000,000 in educational debt, so the third party payers can replace you with a nurse?

Let’s now have a group of paralegals write an article how they can provide better legal services than lawyers.

I am a the only pediatrician living and practicing full time in the area of Columbus, Ohio known as The Bottoms. For 30 years I have seen physicians lose control of the medical profession to HMOs, insurance companies, the government, big business, and attorneys. We have had little input into “health care reform,” and others are making decisions based upon theory rather than upon experience and knowledge. Too often politics and economic greed have undermined the scientific foundations of the practice of medicine.

Would you want a secretary or an administrative assistant to decide what to publish in your magazine?

Your publishing this editorial suggests Scientific American wants to take the science out of the practice of medicine.

You said, “Most importantly, nurses are more adept at some patient-centered activities than doctors, particularly following protocols.”

Do you really believe the practice of medicine can be reduced to a cookbook and that there is no art of medicine but only the “science” of following directions on a computer screen or printed protocol?

If you are correct and need doctors only for diagnosis, you won’t need nurses either but could simply punch diagnoses into a computer and print out the protocols to treat them.

After reading this editorial, I would cancel my subscription to Scientific American if I had one.

Edward A. Cutler, DO

I can hardly know where to begin, considering the biased context and information being proported by such a prestigious journal as Scientific America to be published as if it is factual. The authors are nurses, with an agenda to promote nursing education as an equal to medical education and experience, a massively flawed idea that politically is gaining traction because they supposedly able give “medical care” at a discounted rate. This also goes along with the increased risk of mismanagement by poorly trained and educated nurse in an attempt to duplicate services and knowledge of physicians, I would dare that these individuals perform the complex procedures or post-op care performed by physicians. I also double dare them to demonstrate an ability to perform preventative care in even a 1/10th the depth and understanding for the multiple chronic diseased individuals that a single family practice, internal medicine, OB-GYN or specialist are able to handle. The nurse “extender” should understand what their limitations are, not as an equal, but to assist. In my disappointment at Scientific America, I will never buy your journal again.

I think this article is an interesting perspective but is totally devoid of any science. The authors present their biased views without citing any authority for their outrageous statements. I am not in healthcare, but I have a background in science and know that to be valid, you have to cite some evidence. To make a ridiculous statement such as “Well-trained and qualified nurses can … remove cataracts, and do Caesarean sections”. Where has that ever been done? What are the outcomes compared to surgical procedures performed by physicians who not only completed medical school but also had additional training (internship and residency) for 4 – 7 years longer. Obvious misrepresentations such as this should be confronted and proof demanded before publishing such rubbish. In fact, these claims even call into question the entire premise of the article – that nurses should be more prominent – a proposition that I support. We do need more and better trained nurses as part of the healthcare delivery system. There are things they do well (NOT surgical procedures) such as helping to educate patients in healthy choices and in complying with their prescribed medical therapy. I don’t see any evidence for the claims that nurses are BETTER than doctors because “Nurses are more interested in health promotion and disease prevention, whereas 99% of medical education is about diagnosing and treating disease rather than implementing care plans for healthy lifestyles. Nurses tend to be more comfortable working in teams than doctors.” My mother has a liver transplant 7 years ago. She has a team of doctors including 3 transplant surgeons, a gastroenterologist, an immunologist, a cardiologist, and a pulmonologist. She sees them frequently and together, they decide how to change her medical regimen. There are also nurse coordinators on the team, but that is what they are – a part of the team, not a replacement for other members who have much more knowledge in their specialties. When we extrapolate beyond what is supported by the evidence, the results are rubbish.

“Well-trained and qualified nurses can give anaesthetics, remove cataracts, and do Caesarean sections”

The anesthesia part is correct given CRNA’s but cataracts and C-sections is just a plain lie!

I agree in areas where healthcare is spread thin we need to train nurses to do more then they currently do in developed nations. However by the end of article you are stating that healthcare delivery should be led by nurses. I think that you need to be careful about how much you believe nurse + training = good healthcare practitioner and or leader. I am a 30 yr veteran of Medicine from a Doctors perspective. I train MD, DO, NP and now Physician Assistants. I love them all. They are all great, dedicated and smart people. However as one who trains and works with them I cannot believe that your Nurse-centric Healthcare delivery system is reasonable where physicians are abundant. The difference between a RN training to become a NP and a 3rd year medical student is huge. The thinking is totally different. One has tremendous basic physiologic training with a concept of interrelationships between health and disease that is never appreciated by a student who has only seen the patient from the disease state view. Example: a PA student in ER gets an EKG, they diagnose interventricular conduction delay with a widened QRS, QT prolongation syndrome and bradycardia. The NP isnt sure and calls for a cardiac consult. The 3rd year MD student knowing truly the physics and theory behind the galvanic waves he sees on EKG realizes that this machine was run at twice the normal speed by error and notes that the standard waveform at the beginning of the EKG confirms this opinion. This actually happened. Please remember that we all have our place in the medical care team but get a second opinion before you state “ there is a strong case for building health delivery systems led by nurses rather than doctors.” This may be true for the undeveloped nations but to physicians who train both you need to have diagnosis before we can start the “following protocols for the treatment of patients” regimen.

Most importantly, nurses are more adept at some patient-centered activities than doctors, particularly following protocols for the treatment of patients with chronic conditions like diabetes, asthma and high blood pressure. Increasingly, healthcare is much more about careful chronic disease management in concert with the patient’s preferences and values, than it is about diagnosis, an area where doctors excel.

As a physician, I agree with the above. Nurse Practitioners are pushing their limits of education by diagnosing with out supervision. Acute diagnoses should only be rendered by a physician. Nurse Practitioners are fine with chronic care management. To allow NP’s to do surgery with out medical school and residency training needs to researched in debt. The author does not give statistical proof. All the studies to date have been biased comparing NP’s to Family Physicians as they have been funded by health insurance companies who have link to the lead authors, some of whom sit on their Board of Directors.

The shortage or affordability of doctors is a societal problem. Any real solution has to come from mecanisms that the society needs to put in place in order to truely adress this problem. A real solution will have to either lower the cost of medical education, lower the cost of practicing medcine or a combination of the two. The training of doctors differs from the training of nurses in fundamental ways. The doctors are trained for doctoring, in other words to take charge of a data set, and through their medical education, tailor the investigation until they get enough data to permit a sound medical judgement to be made, or to withhold judgement and refer the patient if the data are not forthcoming. Oftentimes there are too many data and not enough meaning. The most vital part of the doctor’s cognitive skill has two components. First is to be able to criticize his own data, that is the data that she/he herself/himself has generated by the investigating process. Second is to assign meaning to these data, and cautiously but confidently discard the noise. Next comes ordering, prescribing or applying the necessary solution to the problem, that is treatment to the diagnosis. The doctors dissect and reassemble the data. The nurses do not. A doctor uses pattern recognition extensively. However at the same time a doctor is rutinely defiant vis a vis the conclusion acquired through the pattern recognition. This is done by dissecting it’s components, and scrutinizing them, in their own elemental merit. On the other hand the nurses are trained for nursing. The nurses by virtue of their training do not go beyond the pattern recognition. They are trained to execute the doctors orders, and to report what needs to be reported, to the doctor. I am priviledged to work with many excellent nurses that I trust, respect and admire. But ultimately they are not in full charge of my patient. I am.
The doctor’s shortage needs to be adressed by the society. Not by nurses who try to play doctors by supplying medical judgement. Not by doctors who try to introduce factory efficiency in medical practice, by seeing an increasingly large number of patients, within strictly economized timeframe, and end up supplying a wattered down medical judgemnent in a HMO style. In order to achieve this factory efficiency the doctor will have to rely ever more on the pattern recognition and test ordering (that works fast) and ever less on dissecting and reassembling of the available data on a due process and deliberate fashion (that works slow). I am sadened to notice a confluence of these tendences, which makes the practice of medicine more of a semi-automatic processing of patients, categorized by symptom or the presumptive diagnosis at best, than by a truely one on one encounter where the doctor practices his craft by applying the scientific method. If taken to to the extreme, and the extreme might not be too far away, it will not matter who will see the patient, the MD or the nurse practitioner, because they both will follow the same playbook and the same check-list. The patient will be processed by a team where the MD heads this vast team of medical profesionals and plays a prominent role only on the paper, however nowhere to be seen in the actual, factual and true care of the patient, other than in some sort of managerial/burocratic capacity. The specialists will receive ever more referrals by the medical home teams, while the primary care physicians will be rendered ever more incapacitated of downright incompentent to take full charge of the patient, by making a diagnosis, prescribing a treatment, and following through with the results. Instead the patient will be unnecesarily placed in a uber time consuming and expensive conveyer belt of medical profesionals, toggling between the specialists and the primary care. This is already happening at some extent, however, I hope, has yet to reach a critical mass. When and if it does the primary care, as we know it will be dead. Nurses practicing medicine is already not raising eyebrows.
Doctors shortage is a legitimate problem. Some state legislatures are concocting a fake solution by introducing legislation that after creating a role for nurse practitioners are widening and expanding the scope of their practice. This creates the illusion that something is being done. Some laws stipulate that the nurse practitioners have to be closely suppervised by the doctors. The daily reality of overburdoned, time pressured, primary care practices, puts the close suppervision in the back burner. A meaningful suppervision is frequently impossible.
I would not recommend my family members to frequent primary care centers where the doctor is very little to be seen, and where the nurse practitioner is ubiquitous in their care. In fact I would recommend my family members a primary care center without any nurse practitioner, where the doctor truely takes full charge of the patient. A little knowledge can cause a lot of harm, mainly by not knowing and being aware of the boundaries of this little knowledge and what lies beyond.
If I were to be in position to influence the decisionmaking in the macroeconomic level my solutions to the doctors shortage would comprize a) reform graduate medical school training close to european standarts that would require about six years of medical school, rather than four years of colledge plus four years of medical school as is customary in US; b) reform postgraduate training where the medical and surgical specialty training starts early after one or two year of exposure to the general medicine or surgery. There is a huge waste of resources to train them fully as general surgeons and internal medicine, before thay move on to specialty areas. After all they never practice general medicine or general surgery again, or even ever. This will lower the length and compounded cost of specialist training from 6-8 years to 4-5 years for most of medical and surgical specialties. c) Tort reform/malpractice reform, to lower the course of practice. About half of health care spending in this country, in my estimation is made on improbable however still possible ocurrences that have some chance of getting the doctor sued over a lifetime career, although likely make make no real difference over a single episode of care. There is no such thing as zero risk of being sued, however an untold amount of money spend on testing may render this risk pretty low. How beneficial, or even harmful this turns out to be to the patient, is a totally different matter. No matter how prudent or conciencious a doctor is, the one risk that nobody can ever eleminate is the risk of being wrong. The way the malpractice law is practiced, a bad outcome coupled with the doctor being wrong equates with negligence and the doctor is on the hook. So, until this folly is ended somehow, an untold amount of money will continue to be thrown in a bottomless pit. Of course this is all about doctor’s behavioural adaptation toward adverse practice environement and and the monetary cost of this adaptation can not be scientifically measured. Being politically correct has superceeded being candid or truthful. Being nice and a teamplayer counts more than IQ or the lack thereof in many quarters. Not rocking the boat is the most important part of IQ itself in those quarters. Anyway point a, and b will significantly lower the cost of medical education without making any apreciable dent in the quality of medical practice; point c would lower the cost of practicing medicine and all three points would significantly affect doctor’s shortage/affordability. Neither of these points/reforms would cost any money. However it will take a lot of political will, spine and stamina, all in short supply, and nowadays much more precious than government/paper money spruced up by quantitative easing and other gimics.
Conclusively using nurse practitioners as a surrogate doctors is a simple and the wrong choice. To do so would be a gross disservice to the patients and to the practice of medicine.
By putting nurses in charge to practice medicine will not solve the present problems. It has a pretty good chance of making them worse. There are a lot of people who make money, make a living and are trying hard too increase their market share in the business of health care. This is all fine and fair, however it comes down to be able to deliver true value to the patient and for the patient. Tauting up the nurse practitioners, and trying to dress them up as make-believe doctors is not, in my opinion, going to deliver value. It all comes down to acquiring and applying medical judgement. This is the core of being a doctor. This is the core of practicing medicine. I personally know and admire many excellent doctors who were nurses prior to becoming doctors. I applaude any nurse who aspires to achieve just that, however in order to do so he/she needs to go to the medical school. Being able to practice medicine, anywhere in the world, should not require any less than that.

This article reflects a wealth of ignorance about how physicians are trained today, as well as patient’s comfort with physicians. Few are intimidated! As to nurses removing cataracts…. that is simply dangerous. If you can learn everything you need to know in 4 years (BSN) or 5 years (MSN) then why do doctors like ophthalmologists spend 12 years in training?

This article’s points may be relevant to 3rd world countries that are underserved from a medical perspective and where routine care (vaccinations and other preventative issues, as well as basic care for chronic diseases – diabetes, etc.) is lacking. It is preposterous however to apply these points to 1st world countries as well as more complicated care in 3rd world countries. I would like to ask the authors directly if they would be comfortable with a nurse performing a C-section on their family members!

“Most importantly, nurses are more adept at some patient-centered activities than doctors, particularly following protocols for the treatment of patients with chronic conditions like diabetes, asthma and high blood pressure. Increasingly, healthcare is much more about careful chronic disease management in concert with the patient’s preferences and values, than it is about diagnosis, an area where doctors excel.

The greatest advantages of nurses in leading the way toward global health are subtle. Nurses are more interested in health promotion and disease prevention, whereas 99% of medical education is about diagnosing and treating disease rather than implementing care plans for healthy lifestyles.”

There are so many non-sequiturs in this piece it is difficult to find a place to begin.

If nurses can manage diseases better than physicians, then why the emphasis here on nurses doing complex surgical procedures such as cataract operations?

The government loves protocol medicine, but protocol medicine is just that…slavish adherence to a set of guidelines, which are typically the product of a bureaucrat whose goal is cost-savings. Increasingly, we are seeing individual choice by patients, and treatment decisions based on a physician’s expertise and experience, replaced by one-size-fits all flow charts. It’s even questionable whether this approach saves money in the long run, but if you are a patient who doesn’t fit the flow chart, then the protocol might just kill you.

And what, pray tell, does a patient’s values and preferences have to do with treatment of a metabolic or surgical disease. If one has coronary artery disease, then that’s that, and what the patient’s values or preferences are has little to do with it. And no, that isn’t to dismiss patient attitudes and lifestyles.

I find it interesting that it doesn’t appear that any physician contributed to this article.

“Evidence supports the positive impact that nurses, particularly advanced practice nurses, make on quality, affordability and access to care without compromising impacts on patients. “

Let’s see it.

Saying that a nurse can remove cataracts is beyond incorrect, it is irresponsible. With 4 authors, you would think this article would be better researched.

I am a Family Physician and find your article offensive and untrue. I practice prevention daily with every patient. I am more highly trained than a nurse practitioner and more able to juggle multiple issues and medications than a nurse practitioner. Your article is opinion and I would like to know what generated it. Do you have an ax to grind? Are all of you nurses? I do not see MD or DO by any of your names. I do not see any proof that what you are saying is true. I seems to me that you are making assumptions. I do believe that nurse practitioners have their place in medicine but they are not physicians and do not provide the same level of expertise that a physician does. If you want to be a physician, go to medical school. If you want to be a nurse, then accept the limitations of your training.

This is ridiculous. Nursing care is a valued care of the health care network, but can never completely replace physicians in the total care. Even nurse practitioners, while better trained than nurses at some care provided, do not approach the decision making that a well trained physician provides. If you want to train a nurse to do things a physician does (c sections, eye surgery) then you are just partially training a “doctor” and calling it a “nurse.”
I resent the implication that doctors do not see the whole person, and are focused on disease only rather than health. That is an insult and untrue.

I wonder any of you has evidence to support your claim or opinions. Then ask yourself 1 question: Do you really WANT Nurse/NP operate (C-section, cataract…) on you or your families? Be truthfully about it.

This is the most poorly written article I’ve read from Scientific American. I cannot believe that you are implying that nurses are better than doctors at treating medical conditions. Patient with chronic medical conditions are not treated like algorithms that nurses can just follow. Each medical treatment must be tailored for that specific patient which requires years of medical training.
As far as patients being comfortable with nurses vs. physicians. That observation is extremely variable. A lot of my patients refuse to disclose their entire problem to nurses because they feel they are not adequately trained in understanding their condition.

Nurses may be interested in disease prevention and health promotion but that does not equate to them being capable of treating these conditions. I am interested in learning to make different types of food but that does not mean I am a chef!!! This mentality falls under primary care physicians who are specifically trained for disease prevention.

Nursing education is INADEQUATE for them to treat certain medical conditions. I definitely would not want a nurse removing a cataract from my eye…would you?

You have some gross errors in that article. Nurses CANNOT do Cesearian sections, at least not in this state. They can be my First Assistants, but they cannot be primary surgeon for this. Also, they CANNOT do cataract surgery. Again, they can be surgical assistants. I have no doubt that my assistants have done enough to be able to do them by themselves, but they are not trained in surgery and do not have priviledges at the hospitals to do them. I, myself, would not want an NP to do my neurosurgery, remove my gallbladder, or treat my dad’s stroke. They don’t have the training. Yes, routine hypertension, wellness, yearly exams can be well-handled by adequately trained Nurse Practitioners and Physicians’ Assistants. They can be a god-send for both the physician and the patient. However, to be adequately trained for the surgical fields, they need the schooling and the residency and that makes them doctors.

Sounds like an opinion piece.
I’m sorry that I wasted my time reading this article.

Certainly nurses can provide a variety of primary care, particularly for chronic diseases. However I would be cautious about generalizing care in rural less developed nations to care in the United States. I certainly do not think that patients in the US would be comfortable having nurses doing cataract surgery or Caesarean sections. Yes, a technician can be trained to perform a procedure, however much more in involved, including deciding when the procedure is indicated, and being able to handle the complications that may occur during the procedure. This is why the breadth and depth of physician training is much greater that that of nursing. Disease management is much more that simply following a protocol. It requires the training and ability to recognize the complications and variations inherent to treating the individual patient.
The assertions that nurses are more interested in health care promotion & disease prevention, are more comfortable working in teams and find it easier to think about systems than physicians, is unfounded and insulting. Current physician training is much more intensive in breadth and depth than nursing training and includes emphasis on management chronic diseases and care of the whole patient. Physicians continue to be leaders in development of health care systems.
Health care will require greater integration of physician and nurses working in teams to provide patient care. To imply that physicians lack these skills is misleading and disruptive to the cooperation needed to provide development of the models needed for future health care.

This is a shamefully self-serving article with no conflict of interest disclosure written by nurses and representatives of the insurance industry who would seek to have healthcare delivered by nurses not because they provide comparable care but because they cost less.

The bottom line is that physicians are the only providers trained to deal with the full complexities of the human body. The protocols that the nurses in this article follow are written by physicians so, despite what is said disparaging them, they are the ones who drive this organization of care.

Most importantly, physicians are the only ones who have trained to provide care independently. This article would either mislead you to believe that nurses can do the same or, even more frightening, should be allowed to do the same.

Ask yourself, if you were sick or a loved one were sick, would you want to see a nurse or a doctor?

What a load of crap. Ever speak to a nurse or physician about this issue? Even nurses especially the best trained refuse to allow their family and loved ones to be seen by Nurse Practitioners or Physician’s Assistants. Come one, this is an obvious attempt to try and push warm and fuzzy feelings towards social acceptance of less competent and less trained individuals “physician extenders”. If your kid has the sniffles and you just need a nurse, you might say its OK but what if it’s really Leukemia and not just the sniffles? If you have a urine infection and just need a nurse what if it’s really a pelvic infection or bladder cancer? I’m sure a less trained but “doctor” nurse can be just as likely to pick up the subtle clues and initiate the workup. Wake up you idiots, this is a PR article written to place social acceptance on a really terrible idea. There is a reason patients seek out Doctor’s, and a reason there is Medical School, Residency, and why nurses as wonderful as they are are called nurses. By the way, I couldn’t do my job without the many exceptional nurses that support me, but don’t kid yourself for one second that they can also do my job.

Congratulations on a great piece. To bad you couldn’t get it in sooner so that it could have been published in the April 1st edition. Wonderful spoof artcle—-really made me laugh.

Re: “Why Nurses Should Be More Prominent”
What is this nonsense? First, you need to reveal that your authors are not just interested bystanders but are RN’s. Why did they leave there titles off when the authors names were posted????? Second, there is no balance to the article. I can state for a fact that there is No RN within one hundred miles of me that is qualified to do a Caesarean Section. So to state the exception to the rule as if it was common place is misleading. Third, a move backward toward third world healthcare status in the name of saving money will lead to just that third world health care. If these Nurse Practioners are so interested in healthcare and not just the dollar, then why aren’t they out here in rural American an not in the big city?
Put your practice where your mouth is and get out here and help and stop clamoring for more money.

As a nurse for over 10 years who decided to switch careers to medical school, I can confidently say that the above is not only untrue but dangerously misleading. The best nurses may come close (but not equal) to the most imcompetent physicians, but there is no substitute for 4 post graduate years of learning scientific theory and the pains and agony of learning through residency. During one year of residency, one sees hundreds of more cases in a specific specialty than a nurse would see in 3 years. In addition, a physician manages other aspects that a nurse has never had training for.

Medicine is not a “trade” to be learned by apprenticeship. Sure there are aspects of it that are on the job training but that on the job training is not honed unless one has the proper educational background. The requirements to even be admitted to medical school eliminates over 90% of the population, while nursing school requires only what is it these days…2 years? Nursing was an amazing job for me and I loved my patients and fellow nurses but honestly, it was not anything close to how rigorous medical school and residency was. I would never send my parents to a nurse for medical management…and neither should you.

are these the same nurse practitioners who demand to see only the most senior physicians for themselves and family members? i’ve seen the work of most of these newfound darlings of the healthcare system, and most physicians are tired of being their middle relievers.

It seems many allied health care workers want to practice medicine, but don’t want to go to medical school. Where’s the evidence that physicians are not interested in health promotion and desease prevention. I am surprised that Scientific American would publish an article made up of propaganda and clearly a baised and undocumemted viewpoint. Where’s the sceince??

I find it irresponsible that your journal would make a statement suggesting that Nurse Practitioners are adequately trained to deliver anaesthetics, perform cataract surgery and cesarian sections. By current standards, medical students and residents are not able to perform these procedures unsupervised and by half way through their training OB/GYN residents have twice as many years of experience than a newly trained NP. NPs are able to play an important role in health care reform but not as physician substitutes for procedures that the government deems would be financially beneficial. Safe medicine is evidence based – where is the meta data to support years of safe outcomes for NPs performing these procedures unsupervised?

Are you kidding me? Why not just come out and say Doctor’s make for crappy Doctor’s which is why we need nurses to be Doctor’s? “Nurses are more interested in health promotion and disease prevention, whereas 99% of medical education is about diagnosing and treating disease rather than implementing care plans for healthy lifestyles” is at lease partially true. Doctor’s are Doctor’s so if you’re sick please seek out a Doctor. The second half of the statement is completely absurd that nurses are somehow more interested in health promotion and disease prevention and insinuating that they are more capable at this is unbelievably naive and just insulting. What the authors don’t mention in this is that they are at the forefront of pushing legislation to call “advanced practice nurses” by the title “Doctors”. The fact they didn’t come out and simply tell you this is part of the PR angle of this article that tries to change public perception and acceptance of this terrible idea.
One final note to keep in mind “Well-trained and qualified nurses can give anaesthetics, remove cataracts, and do Caesarean sections.” This is somewhat true when all goes well and everything is normal and smooth, i.e. the 80% simple cases. What about the 20% tough cases where the S hits the fan and you have an unexpected finding, or a difficult case or suddenly unstable patient? This is exactly where you need a doctor but if all you have is a “well-trained and qualified nurse” then you’re S out of luck! Either a critical finding is missed, or you have a stable patient end up good and dead or terribly injured. We do need nurses, they are critical in medicine and in providing good patient care! We also need to recognize the true limits of their profession. Maybe its fine to have a nurse take care of you in Backwater Columbia if no MD’s are around, but in the US are you kidding me? Do you think it would be cheaper? Think you’ll get less unnecessary tests or requests for advanced consultations and save money? If this becomes socially and legally acceptable practice in the US we are all in trouble.

Where is the data to support any of the positions taken by the authors of the article?

As a specialist in rehabilitation, my training focuses on the interdisciplinary team approach to patient care and promotion of the health and function of the individual as a whole.

It is stunning to me that the authors making assertions without any offering of scientific data to support the assertions. As nurses, I would expect them to base their opinions in facts and be prepared to provide references. Or is that only expected of Physicians?

Nurses are capable of many things—leading world healthcare is not one of them. I was an RN, went back to school to be a physician. This gives me a perspective unavailable to most. I am too well aware of the things I would be missing without the additional education. For uncomplicated health promotion activities, fine. But ordering unnecessary testing and prescribing inappropriate drugs is all too common among nurse practioners I’ve worked with. Too many referrals to specialists. I have worked with some fine and very capable PA and NP colleagues; but then there are the ones who overstep—they are a menace.

It is a travesty that Scientific American has published an article that cites NO evidence and makes blatantly false statements such as “nurses can…remove cataracts,” something I’ve never seen or heard of as an ophthalmologist. Nurses are a very important part of the health care delivery system and often have more time to “follow protocols.” But unless you think a few years of nursing school are akin to 4 years of medical school and 3 years of residency, then don’t tell me that you want a “well-trained and qualified nurse” doing your wife’s C-section.

These authors do a great disservice to the Medical team as we know it in the USA, by perpetuating the turf-war between nurses and physicians. The medical profession as well as the nursing profession cares for their patients’ well-being. I have worked with as many cynical, cold-hearted nurses as I have physicians. The entire focus of the training for the Specialty of Family Medicine is geared toward preventative care, early intervention, and being a patient advocate as part of a team.
The authors should do more fact checking: For a nurse to state that nurses remove cataracts, or do C- sections is untrue. Nurses are a strong and vital part of the team, and can do minor procedures with advanced training, but major surgery is only performed by Surgeons.
Nurse practitioners as well as Physician assistants are usually under the supervision or liability umbrella of a physician. There are many things that they can do as well, but major surgery is not one of them. Obviously the authors would like to see that change, and in the current health care environment, it will likely happen. That doesn’t necessarily make it a good thing.
They cite the British system, but actually they are now discussing decentralizing it,and returning the health care decisions the the physician and patient as it should be. A good team, and a good nurse would help facilitate that for the patient.

I’m shocked at your statement. Perhaps instead of listing the authors’ “Bios” you should have listed their “Bias.” As well as you own. You’ve lost me as a reader.

This article makes the argument that Nurses can institute Algorithmic “healthy prevention” plans and thus eliminate the need for physicians… What a beautiful utopia….

How many of the authors will seek nursing care when they have a painful condition that requires diagnostic acumen?

I work/employ several nurse practitioners – each one has >20 years of clinical experience in their field —- none of them has the arrogance to feel like they can practice my subspecialty without my input – in fact, while they can address the straightforward patients needs quite well, they still need me… as do my patients.

Your article is the most asinine thing I have read in a LONG time.

I can train a high school grad to do a c-section in about 2 weeks…
I can train a high school grad how to remove a cataract in about 4 weeks
I can train a high school grad how to administer an anesthetic in about 4 months…

learning how to do something, does NOT impart any of the knowledge on how to 1) manage complications 2) assess appropriateness of treatment…

I have been practicing my sub-specialty for 6 years, and despite my 4 years of med school, 6 years of residency/fellowship and my 6 years of further practice, I still am learning and fine-tuning my diagnostic steps and management skills.

this is psudo medicine era and let scientific american become unscientific to support this data

Hmmmm—-Members of the nursing community writing favorably about nurses giving anesthetics, removing cataracts and doing C-sections rather than physicians who have gone to medical school then trained in specialties—-how strange is THAT?

It sounds like you think we should do away with doctors. I am wondering why anybody goes to medical school these days when this attitude is prevalent in the media.

One correction: there are no longer any “general pracititioners” as we all must have a Family Medicine Residency. There is a big difference in training. Do the authors of this article even know that?

To assume that Family Practice Doctors do not do any of the things you are claiming Nurses do is an erroneous premise. When you write an article with an erroneous premise, that means the whole article is in error.

Doctors are to blame for the whole mid-level dilemma as they have accepted the mid-levels by hiring them and because some doctors are not as meticulous as they should be. There are bad apples in every profession. The whole profession is not at fault.

I have stopped training mid-levels because I got tired of them telling me they were better than doctors. Is that what the schools tell them? That is basically what this article is saying.

The most dangerous person in medicine is the person who does not know what they do not know.

The fragmentation of medicine is contributing to a decreasing quality of care. The physical therapist gets to determine when the patient is discharged from the hospital. The social worker has a major part in the discharge. I ask the attending hospitalist about discharge plans and he tells me: “I don’t know. That is not my job.” My feeling is that the doctor should be involved in discharge planning. “Not my job” is not acceptable to me if I am the patient. I want my doctor to care about and be involved in every aspect of my care. That is how a good Family Practice doctor operates.

I do not think we are having teamwork when nurses are writing articles like this one and making desparaging remarks about doctors. Did the editors consider having a lay person read this article before publication? That is the most important – how is this information being interpreted by the non-medical reader?

There are still good Family Practice doctors out here. We work 7 days a week. Some of us still make house calls. Some of us still visit our patients in the hospital because they are our patients – even though there is no reimbursement for that visit. Some of still study every day. We care. We work hard. We are not interested in the politics of medicine, but in the welfare of patients — disease, health, and even in preventive medicine [of which you so wrongly accuse us of ignoring].

Please think twice before you make false accusation about others in an effort to promote your own agenda.

Amilda Heckman, D.O.
Elizabeth Family Health, P.C.
Elizabeth, CO 80107

Was this a paid advertisement, because it certainly reads like one!! This article is more akin to a political diatribe and is absolutely insulting to physicians. Further, it make assumptions regarding medical education that are note remotely based in reality. Furthermore, to assume a nurse is more “holistic” than an Osteopathic Physician is pure fantasy.

As a physician, I completely agree that alot of qualified healthcare workers are concentrated in cities. I find this observation to be true for a couple of reasons with the first being that a myriad of patients also live in the city (thus requiring more services.) The second is a sorely overlooked factor: physicians are people, with all the same desires, families, and interests. I find it unfair to fault anyone who chooses to live where they wish. That said, I fully support any program to increase rural interest in healthcare fields.

However, I find the 7th and 8th paragraphs dangerous and borderline manipulative. While it is true that many nurses can “follow protocols,” might I clarify that man of the protocols were created by physicians who spent hours testing and retesting various approaches. I shudder to think of the number of physicians who put their families in jeopardy because they volunteer their time at free clinics, on philanthropic boards, or getting MPH; all in the name of “thinking in systems.” Broad based generalizations of such polarizing statements is poor journalism.

Because of the fervor by which some people are willing to blur the line between scopes of practice between nurses and doctors, I know of physicians who have begun refusing referrals from nurse practitioners. Only time will tell if this trend continues.

One should note that this article is written by nurses and an executive from United Healthcare (who stands to benefit from providing “care” via inexpensive nurses, rather than physicians). Once nurses were allowed to see patients on their own under the title of “nurse practitioner”, they began to crave more and more power and autonomy. It brings to mind the adage of allowing the camel to put its head in the tent; the original occupant of the tent is subsequently forced out as the camel worms its way in bit by bit. While this concept of power-seeking is inherent to human nature, it isn’t necessarily to the benefit of patients. As the article implies, nurses are more willing to listen to you, hold your hand, cry with you, and let you dictate your own treatment regimen. If I were sick, I would rather have the iconic paternalistic physician tell me exactly what I need to do, write me a prescription, and go to the next room. If I need someone to hold my hand, my wife will do just fine.

Scientific American has apparently removed the ‘scientific’ portion of their moniker. This is a deplorable opinion piece clearly intent on paving the beaches for depriving the population of medical services by trained professionals. This is shameful and in this publication is worthy of contempt. I hope the populace can see this biased fluff piece for what it really is. Shame on Scientific American for giving legitimacy to this.

I am surprised that Scientific America now started puplishing editorial without any data.
I just want to know, when does next editorial that will tell People of United States, not to send their children to be Physician and either become a Nurse Practitioner or choose some other profession.
Thanks

Under appropriate MD supervision Nurse Practioners can be very useful. No way does an RN training program offer the depth or breadth of medical school, internship, and residency experience. To suggest a RN Practioner offers equivalent or superior care and information to an MD is disingenuous and dangerously misleading.

I don’t disagree that well trained nurses (nurse practitioners) can provide care, even procedures, BUT globally, this is properly done only under the supervision of licensed physicians except perhaps where physicians are not available (Africa for instance).

Your conclusions (“more adept”, “less intimidating”, “find it easier”, “more interested”, “evidence supports”) regarding deficiencies regarding the care given by physicians is erroneous and unsubstantiated and your comments are a disservice to good physicians around the world. The only credible statement made refers to “diagnosis where doctors excell”. Unfortunately, nurse practitioners, who are less likely to excell in this area, may not provide the proper diagnosis. Although all the areas of excellence that you credit to nurses alone are important, without the proper diagnosis, these services may be meaningless, even dangerous. The point is that the contributions of both areas of expertise is important and minimizing one reference point in care giving is inappropriate and detrimental.

I’m amazed that your partner publication, Scientific American, would countenance such a non-scientific article. As a caring physician that provides diagnosis, treatment and support of patient’s needs, I am offended by the article, its lack of documentation references and its intent.

If I were to become ill; I would want a doctor to take care of me. The training that an M.D. must pass thru is vast and encompassing. There is no comparison. You are comparing apples and oranges. Now ask yourself the question- If YOU were to become ill who would you want at your bedside? A well trained physician OR a less well trained (But well meaning) nurse.

It is disappointing to see that Scientific American would accept and publish an opinion piece that amounts to little more than snake oil from lobbyists attempting to expand nurses’ scope of care.

The world needs nurses. The world doesn’t need more nurses pretending to be doctors. If they are so interested in practicing medicine, they should expend the time and effort to master the enormous skill set and body of knowledge by going to medical school and completing a residency.

If a nation or region decides that it is willing to accept a lower standard of care from nurses serving as primary care providers, eye surgeons, and unsupervised anesthetists because of social and economic pressures – that is fine. But this needs to be an informed decision. Dishonest and shoddy “research” published in nursing “journals” that simply asserts that nurses provide care equivalent to that of far more highly trained physicians is dangerous and demonstrates a callous contempt for patient safety.

Totally ridiculous. Biased. No scientific basis to backup the material.

Interested in references – many claims made

I’m surprised that a publication as revered as Scientific American was willing to publish a propaganda piece so filled with conjecture, half-truths, and generalities as the above.

First, the authors each have a significant bias. Three work for nursing organizations, and one for a for-profit health insurance company

Second, the nurses make the distinction between diagnosing/treating diseases and “implementing care plans for healthy lifestyles,” but provide neither evidence that such a distinction reflects reality or is meaningful to outcomes, nor that, if true, they have any special training or ability in this area. Diagnosing and treating chronic medical problems, long the domain of physicians could easily be described as “implementing care plans for healthy lifestyles.”

The generalities continue. There is no a priori rationale and no stated evidence that “patients … feel less intimidated and more comfortable communicating with nurses than doctors,” that “99% of medical education is about diagnosing and treating disease,” or that “Nurses tend to be more comfortable working in teams than doctors, who are more individualistic, and some nurses seem to find it easier than doctors to think about systems.”

The fact that nurses are, in some cases, allowed to perform work traditionally done by physicians may represent a necessity or compromise, rather than the ideal. I doubt that, given a choice, most patients would choose such an arrangement.

I suspect their conjecture reflects the talking points of the national nursing organizations engaged in the political process to expand their scope of practice to include domains previously limited to physicians (and which reimburse accordingly). Perhaps the political route to medical practice is less challenging than earning the right by completing medical school and residency training.

I agree with your statements that there needs to be a team effort in health care, as well as individualized care based on the patient’s preferences. Truthfully, I am somewhat offended that you imply that all physicians do not try and coordinate their patient’s care. I completely disagree with this implication and many of the other comments in this article. There is a reason that Doctors receive a significant amount of training on disease diagnostics. Many diseases present differently and with subtle signs. If all Doctors are replaced by midlevels, there will be a significant amount of disease that is missed to the detriment of the patient’s health. In addition, most patients have multiple diseases and the treatment of one disease may be contraindicated in the other disease. If you are not trained to recognize the disease, how are you going to treat these patients?
I understand that in many aspects of health care, a midlevel can perform the same duties as physicians, but there are so many complexities to health care/disease management that I am uncertain the midlevels understand all of what they see. You state that midlevels follow protocols better than physicians. I personally do not follow every protocol to the letter as patients are individuals with many co-existing diseases. Your article states that midlevels have a holistic approach and coordinated their patients care. If they follow protocols for everything, do they actually coordinate anyone’s care? If we are going to make medicine cookbook, then do we even need any type of provider?
I have a lot of interactions with many midlevels, there are some that are excellent and there are some that are very poorly trained. This can be said of physicians as well. When I see the training that is done by the midlevels, it makes me very concerned about the care that is given. An article such as this one is very misleading. It gives the impression that midlevels receive the same training as physicians. The majority of the midlevels were I live did 75 to 80 % of their training online. I doubt that internet based classes really translates into to being able to take better care of patients than physicians.
In regards to your claims that midlevels do c-sections and cataract removal, I really question where nurses are doing these procedures. I have been in many hospitals during my training and as a practicing cardiologist; I have yet to see a midlevel do these procedures. General practitioners can not do these procedures. Why would they let a midlevel provider with less training do these procedures? Anesthesia is a different story. I agree completely that nurse anesthetists do anesthesia and they are very well trained to do so. Their training is very specific to anesthesia. I would never expect and have not seen any nurse anesthetist say they can perform cataract surgery. My point is that the nurse practitioners and physician assistants have a very broad based education; they are not limited to one specific aspect of care. They know a little about a lot. Nurse anesthetists have a much more narrowed intense education and know their specialty very in-depth. I do not believe you can compare these to types of providers.
I do find it interesting that the article is primarily written by nurses. Obviously there is some bias! I have several questions for all of the midlevels; one, are you going to take the legal and moral responsibility for incorrect diagnosis and the consequences that follow? Two, If the nurses are so well trained, why not just get rid of all doctors?

The problem is that people do not know what they do not know. It is true that some nurses will provide better care than some physicians, but given no information other than one person has more education than the other, would you choose for yourself the one with less education?
The statement, “Evidence supports the positive impact that nurses, particularly advanced practice nurses, make on quality, affordability and access to care without compromising impacts on patients.” is not supported by scientific experimentation and there are observational studies suggesting that it is false.

As a physician I do believe that nurses are vital to the the care and health of all of my patients. As part of treatment teams with guided care supervised by physicians, nurses can play a significant role in helping to treat underserved populations where access to care is limited (especially in the context of global health). I would like to see good, objective data proving that nurses are more knowledgeable or adept at screening/prevention (none exists because the guidelines for screening and prevention are an ever changing body of literature). This article starts out under the guise of promoting nurses to help with a global health shortage, but since it is being read in Scientific American, could be confused with generalizing this to health care in America. Americans deserve to be under the care of a physician (who went through an arduous process to be singled out above other applicants based on being at the top of college academics, standardized testing comparing peers across the country, only 1/3 of those applicants yearly are accepted to medical school which is another 4 years of intense education which weeds out the weaker students, and a residency of at least 3 years, to gain a knowledge that is vast and challenging to master) , either solely or with the assistance of physician extenders in the form of advanced practice nurses or physician assistants. This is not to say that all physicians are great, or that there are not knowledgeable and qualified nurse practitioners, but when it comes down to it if I really get sick I wanna see my physician. There is also a significant conflict of interest with regards to your authors backgrounds, it would have been nice to have a counterpoint article or rebuttle from a physician (not employed by an insurance company).

“Nurses are more interested in health promotion and disease prevention, whereas 99% of medical education is about diagnosing and treating disease rather than implementing care plans for healthy lifestyles.”

Oh really? Where is the data showing this? The second part of your sentence relates to medical school curriculum, not how interested physicians are in health promotion and disease prevention. This sounds very much like an insurance company pitch. After all, they would be able to keep a lot more money for executive bonuses if patients are seen by nurses only.

“Nurses tend to be more comfortable working in teams than doctors, who are more individualistic, and some nurses seem to find it easier than doctors to think about systems—leaders in global health require thinking in systems.”

Again, where is your data showing this? So nurses are more qualified than physicians to be leaders in global health, because physicians can’t think in systems? The entire concept of this article is highly offensive, and these are subjective judgements made that are arrogant and insulting. I’m sure that you do have “evidence” that nurses have a “positive impact”, however, it’s more than a stretch for this “evidence” to support your conclusions. I would expect more from Scientific American.

For a scientific journal, it is interesting to see an article written without supporting data, written by people with a clear political agenda. I will believe the above when I see studies proving the non-inferiority of nurses to physicians across a broad spectrum of care. What is in this editorial implies that medical school is a waste of time, and nurses should be given equal status or primacy. Sounds like self serving propaganda.

Hmm….

I like to know that my health care is being overseen & managed by the most capable and well-trained. While there are always exceptions on the Bell Curve of Life, the average Board Certified Physician has more much more extensive training & experience than the Advanced Practice Nurse. Interestingly enough, physicians are also holistic, patient centered, and very experienced in leading health care teams (because that’s what they do now).

I’m sure the many pilots could likely figure out the controls of a 747, however, who would you want flying you?

Nurses are absolutely essential to health care and there are many excellent ones. However, they are not doctors. Let doctors be doctors & nurses be nurses. Then those who want to be doctors can go to medical school & those who want to be nurses can go to nursing school. That option is still available to everyone.

It is hard to know where exactly to begin to rebut this nonsensical piece of self-serving rubbish. And, yes, I am a physician.

Most of the skills highlighted in this opinion piece could be imparted piecemeal to interested but otherwise non-medically trained personnel. So why the need for elaborate nursing education? Dietitians, for example, are far more qualified to deal with nutritional deficits than nurses.

The third world has many challenges to health, most of which are related to public hygiene, food source contamination, rampant poverty and political instability. Do nurses receive training in political diplomacy and economics?

The gratuitous comments about the “medico-academic-commercial-governmental interests” are frankly bizarre. What exactly are nurses preventing if not disease? Much of what the authors call preventive care is in fact monitoring of existing disease. By definition the disease itself was not prevented but is being treated. How is that different from what a physician does?

For the record, the 19th century was dominated by a blossoming of medical knowledge concerning anesthesia, surgery, communicable disease, tumors and the like…. by physicians (not nurses). The last half of the 20th century was the first time in history that a sizable number of physicians actually began to make a true living by practicing medicine. Independent nursing practice has never existed as a self-sustaining economic model.

Nurses have only recently begun to foray into the realm of independent practice. Physicians have been doing it for centuries. I would be interested to see how nurses would propose to fund their activities other than by charity, or more likely, government subsidy. In the US, most physicians own and operate their own practices which they pay for out of their own earnings.

The authors’ final comments are completely beyond understanding. In their own words, the effects of nursing are “subtle”, but they anoint themselves the bold new leaders of a new health paradigm. Do the authors really think a bold, new initiative should only have subtle effects? I believe they also doubt their ability by opining in the title that they should be more “prominent”. Talk about laying it all on the line!

Nurses are an integral part of the healthcare team, but they are not the true leaders. The woodwind section is an integral part of a symphony, but they do not lead the band. If you want to lead, there is nothing preventing you from going to medical school.

This editorial may have merit if the discussion is about healthcare in a Third World country with limited resources. It lacks any substance if the authors are referring to anywhere else.

I find the author bios interesting: quite well represented by UnitedHealth and nursing interests—conflict of interest might be fine in a journal of political opinion, but in an “objective” and otherwise respected science publication? Where is the data that backs up the spurious assertion that “nurses are better suited than doctors to health promotion and more likely to be where the problems are”? The last three paragraphs make some pretty bold claims—I think readers of this magazine deserve actual evidence instead of being spoon fed a hefty dose of opinion by four disingenuous authors whose interest is clearly conflicted.

Tort reform has to be accomplished before these great ideas can be implemented. In 25 yrs of practice, most with the help of one fantastic nurse practitioner, OUR only lawsuit came as a result her advice to a patient. She did exactly what I would have done and did nothing wrong. But the courts did not recognize her authority & expertise.

The world can use more health care workers of various types. Some of the statements made in the editorial are misleading. True, trained Nurse Anesthetists can perform uncomplicated anesthesia—and are usually compensated for this at about $200,000 a year in the United States (more than most pediatricians and most family physicians). RNs—the nurses most people reference as typical clinical nurses—often have exactly two years of college education. Compare this with the minimum for physicians of eleven years of college and advanced training. These are very different kinds of health care workers.

“Nurses are more interested in health promotion and disease prevention.” Now I know why I became a physician; so that people could tell me I really didn’t care. As a practicing medical oncologist who understands the benefit of practicing “healthy living”, I resent the authors opinion and find it offensive. I believe that I speak for myself and my colleagues, when I say that hearing preposterous statements such as those mentioned above will serve only as an impetetus to benefit the few who think they can do better. Do better with less training and less knowledge base, while allowing for much more harm than good to be the principal outcome. Yes, well trained staff can perform cataract surgery, can outline a weight loss program and promote a healthy lifestyle. They can even administer anesthetics or perform bone marrow biopsies. But all of this is done under close scrutiny and physician direction. Why…? Because as physicians, we ARE the diagnosticians; and physicians make treatment decisions based on those diagnsoses. As we struggle to make treatment algorithms to help the few treat the many, it would be best to remember that without the right ingredients, no good can come of any recipe. No matter how we strive to prevent illness, there will always be disease. Hopefully, the politicians and the nursing pundits won’t forget this.

It’s not entirely surprising that an article written by nurses is calling for more autonomy. As a physician, I have to disagree with many of the points mentioned. First I do agree there is indeed a role for nurses with advanced training. I agree that that role should involve prevention and adherence to protocols perscribed by physicians. The education and experience are not the same no matter what the nurse orgs would like you to believe. You could train a high school kid to remove cataracts and do a c-section but should we? What happens when that cataract is complicated or the section goes south? Then what? Once off “protocol” it’s the physician who has the background and training to deal with it.

Before I begin my rant against this profoundly biased and frankly inaccurate article, let me state that I am a physician who is married to and very much in love with a certified nurse-midwife (i.e. an advanced care nursing practitioner in the field of obstetrics).

In regards to the statement above, let me first point out that none of this is science. Not a single statistic or study was mentioned. This is all purely subjective, frankly, hogwash, coming from the senior vice president of the Center for Nursing Advancement and company. I think Mr. Bazarko’s title here demonstrates how much we should value his subjective opinion. Keep in mind he is not the vice-president of the “Center for Advancement of Patient Care.” He is vice-president for the advancement of nursing, and his goal is clearly just that.

I do believe that there is a strong role for mid-level practitioners and advanced practice nurses in American medicine, and, more than that, that there will be the financial necessity for such, given the changes in the American age demographic (i.e. the aging “Baby boomers”), budget constraints and the perhaps inappropriate fiscal priorities held by the American government and people as a whole.

I do take exception to the majority of the editorialazation, which capitalizes on the positive stereotype of the kindly, caring nurse and the negative stereotype self-absorbed egotistical physician. These are no more representative of the whole than any other stereotype. Having trained simultaneously with my wife, I in my internal medicine residency, she in her nurse-midwifery program, both at the same Ivy league institution, I can assure the public that preventative care, patient-centered care, treatment of “chronic conditions like diabetes, asthma and high blood pressure” remains a very high priority for the physician. We do not, however, have the ability to follow patients around and smack the cigarette or Super-sized double bacon cheeseburger out of their hands, nor to chase them around the block to ensure they get daily exercise. Neither do nurses. What nurses in our current model of care do have in terms of advantage over the physician is time. They cost less to hire, and thus are allowed more time with patients. As a physician who has frequently cursed the 15-minute blocks he is allowed to see patients in, I envy that. I also resent the implication that being denied the luxury of extra time with patients makes me less concerned about my patients, or somehow makes the nurse with a 45 minute time block more concerned than I am. What’s more, as nurses and nurse-practitioners take on additional responsibilities, they will continue to face the same growing time constraints as practicing physicians.

Therein lies the rub. The fact of the matter is that there is no mystical training in being compassionate or training for treatment of chronic disease that nurses or nurse-practitioners receive that is denied to physicians. What they do have is three years of post-graduate education relative to the minimum of seven years of intensive training required to be a physician. As a result, they are more readily available and come with a lower price tag. As individuals they can be wonderful or terrible people. They can be intellectually brilliant, or just smart enough to get by. Just like doctors. There are definitely gaps in our current health care system that midlevel practitioners can and should fill. Just don’t expect magic. Except from my wife.

Nurses are trained to follow orders. Physicians are trained to write the orders that nurses follow. A well trained primary care physician doesn’t just blindly follow protocols for chronic disease management. He or she individualizes the protocols for the needs of a particular patient. These needs may vary because of comorbidities (other diseases the patient suffers from), and differing cultural, financial and family situations.

Oh, and one more thing. The primary care physician’s job also involves making sure that the specialists treating a particular patient didn’t screw up, and didn’t order something that conflicts with something another specialist is doing, or plans to do. So the primary care doc needs to know way more about what the all the various specialists know than the rather limited specialty knowledge available to someone who trained as a nurse.

Well this is certainly news to us MD’s who do practice medicine after going to medical school, internship, residency, fellowship, then owe hundreds of thousands of dollars and pay enormous sums for malpractice. It seems that we should just cut out medical education and training and costs and just let the nurses do the job. It’s a losing battle for us dumb MD’s.
Why dont we go to nursing school instead.

the worst mis-informed rubbish that i have seen by what i thought was a good magazine. let a nurse then do all these things that we have trained hard for years in our respective residencies. not for my family members and God help you when primary care practice nurses have something other than cookbook case. self-promotion for the sake of self-promotion is truly offensive. next you will expect us to address a nurse practioner who achieved a Ph.D. as “doctor”.

Doctors did the original investigative work to discover what illness was and defined it. Doctors did the original investigative work to discover what health was and defined it.
Doctors did the original investigative work to determine what converted one to the other.
Without them, nurses could not define what chronic disease was and how to affect a change. For an example, look at simple things like Berri-berri and scurvey.

Having spent 22 years providing care for thousands of patients I guess I missed the memo on how bad a job we do as physicians. Dealing with the multitude of complaints in 15 min slots leaves little time for such lofty endeavours that nurses have apparently mastered. Despite over 200,000 office visits I still feel challenged 4 to 5 times a day. I still make time to talk about creating health and establishing healthy habits. I suspect those touting the strengths of nurses and the shortcomings of physicians have spent little time trying to unwrap a complicated case while appearing unrushed, knowing there are 4 other people in the waiting room with their own list of problems. Good luck in the batters box. BATTER UP.

71 comments and not a single one actually posted and readable? What gives?

Claims of basically all physicians avoiding preventive care are unfounded. It is important to understand what has happened to nursing in the United States to be able to evaluate the role of advanced practice nursing. Most evident is that nursing has embraced the medical-industrial-subspecialty-hospital-academic priority. This has been later than physicians but at a much faster rate. Sadly the reason has been poor US support of nursing, but nonetheless nurses could have remained in the careers and locations needed as certain types of physicians have done, but have made other choices.

Basic nursing and basic health access have been left behind as advanced nurses departing basic health access now have increasing salaries, make more for employers, cost less for employers than specialty physicians, and do not impair the revenue generation of specialty physicians – This is a win-win-win for all – except those left behind in need of basic health access – the reason for nurse practitioners in the first place.

First the NP changes involved movement from less formal and well distributed (often training with rural family physicians) to longer training and training in more centralized locations – just like academic medicine. And lately the same longer and more centralized and specialized and academic training has taken a greater toll.

Basic nursing workforce is the real issue. Primary care registered nurses are a critical component of primary care delivery. Since the choke point in expanding primary care delivery is about primary care workforce (not health care coverage or places or homes or innovation or reorganization), the failure to expand primary care nursing is a huge issue. The other failure in primary care workforce is primary care physician workforce.

The data: HRSA nursing workforce reports from 2004 and 2008 – essentially no increase in basic degree nursing or at least not keeping up with population growth. Recession changes and increased advanced degree nurses may indicate an actual decline in basic degree nursing – a historic first. Also this is at the worst time with massive increases in demand for all health services and more basic nurses. The best nurses and nursing faculty are also being taken, a huge issue for cost, quality, and access in more than primary care.

The data: Nurse practitioners have delivered less primary care and have declined in primary care delivery per graduate. HRSA 2004 data has only 64% of nurse practitioner graduates in nurse practitioner careers. The same is true in Vermont studies. Many are still involved in hospital practices or are part time or inactive. NP delays in entry leave only 27 year careers (after RN degree, RN experience, and NP training). NP primary care (adult, pediatric, family practice) is down to about one-third of NP graduates. Also NPs pride themselves on lower volume. By multiplying 27 years times 33% primary care times 65% active times 65% volume the average nurse practitioner graduate at best delivers about 3 to 4 Standard Primary Care years per graduate. This compares to 13 for pediatric residency graduates and 25 Standard Primary Care years for family medicine residency graduates. It takes 8 NP grads to provide the same primary care delivery as a family medicine residency graduate and the number keeps climbing with decreasing primary care retention in NP.

Also nurse practitioners are leaving the family practice mode. This is the broadest generalist mode in practice (not in training) that is the only career choice that multiplies distribution of graduates where most needed. NP family practices mode is already down from 50% to 25% in the past 25 years. The primary care, rural, and underserved workforce goes away as NP departs family practice. Big winners include cardiology (over 6%) and other internal medicine subspecialties where NPs are already at twice the percentage of physicians and increasing (AANP data).

The so-called “medico-academic-commercial-governmental” interests that have dominated physicians for the past 100 years have been more rapidly implemented by nursing leaders – and at the cost of basic health access focus.

The requirement for 2 more years of nurse doctor training represents a loss of 2 years of workforce, 2 years of less primary care delivery, 8% of total workforce, and likely lower percentages in primary care as with longer and more formalized training in past NP and longer and more formalized family physician training. The current 60 million expenditure by HRSA for advanced nursing training will actually result in less primary care due to workforce losses in fewer career years, in faculty expansion, and in lower percentages.

Advanced practice nurses have become valued members of all types of health care teams across a wide range of locations and have gained widespread acceptance, but the cost has been departure from basic nursing and basic health access. When residents in training had work hours restrictions there were departures of primary care physician assistants and nurse practitioners to fill this hospital and specialty workforce gap. This was also confirmed at the recent AAMC Physician Workforce Conference. There was no response about the decline in basic nursing by experts or by the nation.

The 6% annual growth from 1980 for nurse practitioner annual graduates has allowed two-thirds to enter hospital and specialty careers with increases past 8000 per year and with higher rates of specialization. Meanwhile family physicians that remain in primary care at 80% or more with top activity and volume and years in a career, the same family physicians that remain in family practice and distributed to rural and underserved locations, the same family physicians with multiple times greater service to the elderly and poor and CHC and near poor and rural (Ferrer, Rosenblatt, Bowman) – remain at just 3000 annual graduates – zero annual growth over 30 years for the universal solution for the major basic health access woes of the US.

What a great system. We will have the nurses replace the physicians. The medical technicians can be the nurses. The janitor can work as a medical technician freeing up the physician to mop the floors and clean patient rooms.

4 years of college. 4 years of med school. 3 years of residency. 3 years of fellowship. I must have wasted an awful lot of my young life to train in my specialty if us physicians are doing such a terrible job.

Each and every member of the medical team has a role they need to play and when they do, the care is always better. Nurses are critically important parts of the medical team and without them, patient/disease management could not be accomplished. The best functioning medical systems use a team approach and have clear delineation of responsibility. Your team will not win the world series if you decide to use the starting infield for your starting pitching rotation.

Non-medical people need to wake up and realize what is going on. Your healthcare is being reduced to a simple transaction that your government will have complete control over. Step 1: hire RN’s to do MD’s work. Step 2: Pay RN’s less than MD’s make. Step 3: Less social security benefits to pay as patients drop like flies…

I wonder why Scientific American even ventured to publish this position statement without researching the bonafides of the authors. Where are the editors? The less you know about a subject, the more you think you know. An old Sanskrit adage that translates to “Without Knowledge there is no insight”, is so fitting for this article in a journal I hitherto loved to save for my kids..
Let us for a moment believe that nurses, noctors and PAs are so darned good at human communication that they can read into the minds, hearts and genetic codes of their clients just by gentle talk, listening and holding hands to prevent disease, why then are they treading into areas like procedures, complex diagnosis and management? Do you have any idea what it takes to be a good internist or Surgeon?
Would you really want one of the authors of this article to be calling the shots ( or even taking orders from your doctor) when you are in an ICU or on hospital floor?
If the third party system of medical insurance were abolished today, how many of these “Gentle Beings” would still want to play doctor?

This is one of the most ridiculous article I have have ever read. The statements are backed up by zero data. Faulty premises backed up by no data leads to dumb conclusions. Typical nursing propaganda. Nurses, not just advanced trained nurses, are often the greatest barriers to evidenced based care. It is a joke that nursing “experts” believe that care plans and protocols trump training, experience, evidence when it comes to the care of often complex patients. What happens if the care plans of a patient with multiple problems conflict? What if a patient doesn’t fit into a care plan or protocol? Are nurses willing to take the liability as well as the responsibility.

“Scientific American?” Yeah right… More like…“Not-Scientific American.” Geeeeeeeeeeeeez.

i don’t buy for a second that any of these “doctor-nurses” believe their skills to be equivalent to that of a physician until they explicitly state in one of these articles that they welcome lawyers to make them the primary target of a lawsuit when a bad outcome results from their care. as long as the disclaimer is there, that the care is being directed by midlevels but if something goes wrong the lawyers should go after the supervising physician, all their claims that american health care can be primarily delivered by doctor-nurses ring hollow. put up or shut up.

Google “nurses strike”: 2,480,000 hits. Google “doctors strike”: 361,000 hits. Nurses as leaders of health care? Not if they walk out on their patients first.

Not a single rebuttal comment has been made. SciAm might ask authors of this piece to respond, because I am very curious as to what it would be.

The only conclusion one can logically draw from this propaganda piece is that we do need more nurses…

in Africa where the sick people are.

I am the editor of Lives.

I appreciate everyone taking the time to share their views on this article. I have drawn the attention of the authors to them. Unfortunately, an online glitch prevented them from being read until yesterday.

The publication is called Lives: New Answers for Global Health. This piece was published within the section called “In My View” which was summarized in the print magazine as follows: “A topic as important as global health inevitably evokes strong opinions. Here, prominent experts from across the world share some of theirs.” I apologize if it was not clear online that this is an opinion piece, since readers might have had different expectations of an appropriately labeled article.

The authors are senior, highly respected people in their field, well qualified to contribute an opinion on what they view to be an important issue in global health.

Richard Gallagher
Editor, Lives

Given this line of reasoning, flight attendants should be more prominent in the cockpit.

Wow, Scientific American, your editorial staff is really deficient to have let such a slanted editorial be published. How you could possibly get behind the most disappointing trend in American health care, namely the dumbing down of medicine, stupefies me.

Now someone with essentially NO TRAINING BUT SCHOOL can be qualified to make life or death decisions. Universities are churning these people out and they are wreaking havoc on the public with their ignorance, but this is “OK” with you.

The NP experience will be looked upon with the same historical perspective as the primitive days of medicine, before real standards were implemented. These inexperienced practitioners will produce a wave of litigation for errors in care.

I really can’t believe a publication like Scientific American would publish such an unbalanced article written by two authors who are in some way connected to nursing associations and a third author who works for an insurance company (nurses = less $). It has really brought down my respect for this magazine.

Off to the rubbish pile!

What an extraordinary article to have brought such vitriol from physicians. I would love that fact alone if I did not feel that I was in a time warp. With the exception of the phrase “remove cataracts, and do Caesarean sections”, which seems to have drawn the most ire; the article proposes strategies which are already in place in many parts of the United States. From the early 70’s compelling evidence has been presented about the efficacy of nurse practioners. Data has accreted over the years that is irrefutable. Perhaps hospitals are welcome workplaces for some but the reasons for that are many. This does not refute the excellence of preparation and practice but rather supports it.
My only criticism of the article is the implication of “all doctors and all nurses” for some of the positive and negative statements. As a nurse this would have registered with me but after reading the letters my second reading made me more understanding of the hypersensitivity of the physician readers. But overall my comments to my colleagues would be that neither physicians nor nurses can solve the vast problems facing us alone. It is not too late for true collaboration but it takes mutual respect not hierarchal constructs.
Claire M. Fagin, PhD, RN
Dean Emerita, Professor Emerita
University of Pennsylvania

I think the explosion of comments noted above speaks for itself in addressing the ridiculousness that is this article. I will, however, contribute to the voices above in relating how this article is self serving and poorly written. Not to mention the fact that it is completely biased.

please, show up at my hospital with a complicated set of diseases. I would love to have you see the NP or PA alone.

I am not extending my subscription to PSEUDO – scientific American, as there is clearly no science behind this ( and other) articles, just a pure left-wing agenda – in this particular instance – the need to lower the quality and cost of medical care in order to make it universal and “affordable” should first be implemented to the minds of general public…

please, let the nurses then pay for their own malpractice and run their own clinics and recruit their own patients. oh what? no insurance would touch them?

Welcome to the future of healthcare. Hope and pray you don’t get sick!

While I cannot speak for removal of cataracts or C-sections I can factually address the issue of nurses delivering anesthesia. There are approximately 80,000 anesthesia providers in this country. Forty thousand of them are nurse, we are CRNA’s and we work in every setting in which anesthesia is required. We deliver anesthesia for every kind of case from transplants to cataract removal, many such as myself operate independently, and all practice under their own license and malpractice insurance.
We have been delivering anesthesia for over 100 years and 65% of the anesthetics in this country are delivered by CRNA’s.
As for the assertion that nurses are unsafe or poorly trained there has not been one study indicating that MD delivered anesthesia is any safer then nurse delivered anesthesia, but there have been multiple studies showing equivalence.
Physicians play a hugely important role in health care to say the least and they will never be replaced.

It is unfortnate that this article is being construed as an effort to replace physicians with nurse practitioners and midwives. As a nurse-midwife I only know of one instance where midwives in a seriously medically underdeveloped country were trained by an obstetrician to do a cesarean section as an extraordinary measure to save the life of a mother who would otherwise have died. The major thrust of this article, as Dr. Fagin has pointed out, is to bring attention to a systems approach for developing the teams of care providers and resources needed to more efficiently and effectively match the needs of the population being served. It is unfortunate that it is being interpreted as an effort to replace physcians with other providers of care who are also qualified in their respective areas of practice. IMHO it is pointing to creating a horizontal systems approach in which each team member is respected and valued for their individual contribution to a unified effort to improve quality, affordable care for all of our people. Collaboration rather than control needs to be the focus to accomplish this.

Mr. Gallagher:

As the Editor of Lives it is assumed that Scientific American finds merit in the expressed opinions unless your publication is only a conduit to any and all assertions no matter how preposterous or inane…nurses doing surgical procedures? Aw, C’mon!!

Wearing my editor hat (Rural and Remote Health) and my various article review hats, these are my suggestions for a similar submission.

A rewrite of the article by this author would be required to better represent the 2010 Year of Nursing, the role of the authors, the role of nursing, and solutions for the most challenging health care problems. This article could note:

This year 2010 is the International Year of the Nurse. As representatives of advanced nursing, as representatives of global health promotion efforts, and as corporate sponsors of nursing advancement, we report and encourage a greater role for nurses in the prevention of disease and the promotion of health. We join government leaders in all nations, physician leaders, and others who aspire to greater health access and global improvements in health care.

At this point the article could continue with any of the elements prominent in the http://www.c3health.org/c3activities/ site that should be well known to author Hancock, director of this nursing collaborative. I find it difficult to believe that a director with responsibilities including this fine site including impressive organizational skills could tolerate the submission published that is poorly organized and misrepresents true nursing accomplishments.

The article should close with a listing of areas of nursing progress on the global front lines where health care is most needed.

My comments:

Provocative works are important to raise awareness, but can also inflame allies. This inflammation is apparent involving allies in health promotion and basic health access that have been misrepresented and disrespected. There has been little progress addressing basic health care and the populations involved are more than a majority of the population in most nations, including the United States. Efforts to resolve disparities must be collaborative in nature because the deficits are vast, the appropriate expenditures are small compared to even basic needs, a common strategy is to pit various reform proponents against one another, and it is all too easy to leave basic health access behind – as indicated by the direction of advanced nursing in the United States. The same is true of most physician primary care efforts. Add to advanced nursing and primary care physician efforts the promotion of primary care training that fails to result in primary care most of the time.

Nurses deserve to be more prominent in their role in prevention of disease and promotion of health, but this role has best been accomplished by basic nurses serving basic care that is clearly most needed in the United States and across the globe. United States nursing has not found a way to increase basic nursing supply and support to sufficient levels and new efforts have acted to diminish the most important contributions of nursing.

The article notes nurses to be where the problems are, but this again is restricted to basic nurses. Departures from basic nursing have led to departures from the most complex health problem areas. Even in advanced nursing, departures from the family practice or broadest generalist mode in practice has resulted in substantial and progressive declines in the ability of advanced nursing to deliver on primary care, rural, and underserved workforce promises.

Advanced nursing, particularly in the United States, has not demonstrated the ability to stay with basic nursing and basic health access. Until if finds a way to completely address basic nursing and basic health access, nursing should remain focused in these areas rather than moving into other areas where workforce is available or may even be excessive.

Nursing must also include basic nursing and basic health access nursing representation in leadership, in government reports, in promotional efforts, and in academic components. Nursing literature, nursing leadership, and nursing journals and reports must make vast improvements in one particular area essential to real progress – the ability to self-critique.

Physicians do have the ability to self-critique in many if not most areas. It is quite tragic that various media, journal, and association efforts reference these critical works broadly to criticize physicians broadly. It is essential that specific research be used specifically, particularly when government and the public have such poor understanding regarding health care.

When faced with nursing or social work or other areas outside of my area of expertise, I work with journal staff or colleagues to find appropriate reviewers.

It is the primary task of the media to raise controversy as this is the route to advertising and greater revenues. It is a difficult task of scientific works to remain separate from such influences – a more and more difficult task with fewer separations between those who benefit from advertising revenues and those who produce and disseminate important scientific information. Associations and journals also have more and more difficulty with this area. What people believe and the truth have become more difficult to separate and those who are in charge of “the truth” have a more difficult task.

A fascinating article, made even more fascinating by the online vitriol which would seem to predominantly emanate from North America.
Over the last decade the ratio of doctors to nurses in NHS hospitals has risen whereas in General Practice the opposite has occurred. eighty percent of all patient encounters occur now outside of a hospital setting.The delivery of routine long-term condition management, introduction of the Quality and Outcome Framework and autonomy to fashion workforce appropriately to need are some of the forces at work creating much more of a team approach to healthcare delivery in primary care in the UK. the benefits of this are apparent in the benchmarking published by the Commonwealth Fund (Mirror, Mirror On the Wall 2010)
As a GP, I frequently found the support and advice of our vastly experienced Practice Nurse and the Nurse Consultants in the local specialist services, of critical importance in the management of established chronic conditions. Of course both doctors and nurses have important roles in the system but the attitudes revealed in the responses to an article articulating the challenges facing health systems across the world probably say more about the culture of the medical profession than anything else.
In the 21st century health care requires a team approach. The trouble is – most doctors play golf.

Nurses already are leading the way in health promotion, so to suggest that they should have a more prominent role and increased recognition does not at all seem to be a polemic or startling idea, at least not for those familiar with the challenges that exist when looking at the delivery of health care services on a global scale. As individuals, nurses frequently take on many roles and tasks traditionally carried out by physicians, especially in less economically privileged societies. As a profession, nurses have paved the way for patient-centered care, so why should it be surprising that they would continue down this path? Just take for example the transcultural nursing movement, which far pre-dated the cultural competency wave that is occurring within the United States at the moment (and similar movements elsewhere in other wealthy nations related to health/health care disparities/inequalities/inequities). All of the professional disciplines in health care should be wiling to learn from each other, as members of the same care team. To react with outrage at the mere suggestion of interdisciplinary knowledge transfer and mutual respect does not put the patient first. Quite the contrary.

I have practiced as a Family Physician for 23 years and the article in no way describes my interests or practice style. I spend alot of time with my patients including counseling and education. This practice style however, is not financially viable. Insurance companies will not pay MD’s for this work. I do find nurse educators very helpful and believe that we should work as a team but don’t believe MD’s should be forced out of preventive care.

Clearly—this onslaught of responses is written by 1) physicians working in the US who 2) know nothing about global health because they 3) have never heard of task shifting, 4) do not understand that on the front lines in the battle against poverty and disease, there are no doctors or not enough to meet the needs of the population and 5) misunderstand the point of the authors, they suggest not to replace physicians but to create a stronger cadre of players—especially when the alternative is not physicians by community health workers.

Your article lacks any substance. I supervise nurse practitioners. When they just start, they have the medical knowledge of a 3rd year medical student. That is expected given that the NP school is 2 years. In the first 6 mths of practice, they do not even have the rights to prescribe on own, since they do not have a furnishing number ( similar to medical students). The knowledge is frequently very superficial. While they do acquire more experience after practicing for many years, they rarely have the depth to recognize trouble. They have to consult for anything that is a little bit out of the ordinary. Yes, they can be a great part of the team, but having them entirely replacing physicians is dangerous and stupid. Give physicians more reimbursement for medical advise/ prevention, and you will get more comprehensive coverage of preventive measures like diet, exercise etc and happier patients.

Nurses are not doctors. Nowhere in this article is that suggested. I am frankly saddened at the blinkered view of the main body of responses to his thought provoking article. For goodness sake at what point do the authors suggest nurses should be taking over from medics in N.America? There is a clear statement about global health and the distribution of adequatly trained health professionals. My understanding of this article is that nurses have a wealth of knowledge , skills and experience which if tapped could have a beneficial effet on the health and well being of many individuals in less developed countries.
It is not suggested that nurse training has the breadth or depth of Medical training. However, this article is suggesting that there is a level of expertise which , if exploited, and guided could ‘make a difference.’ The many specialist nurses and advanced practitioners practising in the U.K. are able to manage certain chronic diseases perfectly well. Because they manage the services well they also know their limitations and when appropriate referrals need to be made.
I subscribe to a small charity named ‘Concern Universal’. This charity sends midwives into remote areas to teach lay people the rudimentary requirements which promote a safe birth. This is the kind of work this article is promoting. If it works with childbirth why not heart failure, asthma, diabetes?
So chill! This article is not about undermining doctors . It’s about trying to give some hope to those who have no chance of ever consulting a physician.
In some parts of the world there needs to be a move away from the 4 ‘D’s of Doctors, Drugs, Disease and Death to the nursing concepts of Change through Communication,caring,community and ofcourse Compromise.

I am currently a student, studying Global Health and Wellness. If reading this article from a global sense, where there are rarely doctors available in remote settings but with nurses available, in countries with no standardized medicine, which is better? No Care at all? Or some care that can at least be tried? When there is much at stake, why not at least see them have some hope. Or should the nurses just stand there and let them die?